What Is H0004?
H0004 is a HCPCS Level II code for individual behavioral health counseling in the context of alcohol and drug treatment. Reimbursement ranges from $40 to $90 per session depending on the state Medicaid plan. This code is used primarily in substance abuse treatment settings and is not interchangeable with standard psychotherapy codes (90834, 90837). Medicaid is the primary payer for H0004 claims.
When to Bill H0004
- Individual counseling sessions focused on substance use disorder treatment, lasting at least 15 minutes.
- Sessions provided by licensed or certified substance abuse counselors, social workers, or other qualified behavioral health professionals as defined by the state Medicaid plan.
- Treatment that follows a documented individualized treatment plan with substance use disorder as the primary diagnosis (F10-F19 ICD-10 codes).
Documentation Requirements
Document: session date and length, patient's substance use diagnosis (ICD-10 F10-F19), treatment goals addressed, interventions used (motivational interviewing, relapse prevention, cognitive restructuring), patient response, and next steps. State Medicaid programs audit H0004 claims for session length compliance and diagnosis match. See substance abuse billing for additional coding guidance.
Common Denials
| CARC Code | Reason | Fix |
|---|---|---|
| CO-50 | Not covered | Verify H0004 is a covered benefit under the patient's Medicaid plan |
| CO-16 | Code mismatch | Ensure diagnosis is F10-F19, not a general mental health code |
| CO-39 | Session limit | Request additional sessions with clinical justification |
Common Questions About H0004
Can I bill H0004 and 90834 on the same day?
Check your state Medicaid policy. Some states allow both if the sessions address different treatment goals (substance use vs. mental health). Others consider it a bundling violation. When permitted, use modifier 59 on the second code.
Does commercial insurance cover H0004?
Rarely. H0004 is primarily a Medicaid code. Commercial payers typically require standard psychotherapy codes (90834, 90837) for substance abuse counseling. Check the payer's fee schedule before submitting.
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This reference is for informational purposes. Always verify against current payer policies, CPT guidelines, and CMS documentation. Last updated: 2026-04-06.