FQHC Behavioral Health Clinical Network Retreat 1 Behavioral Health Services Agenda Provider Enrollment Review Policies and Procedure Review Behavioral Health Boot Camp Questions 2 1
Disclaimer The materials presented in this workshop are NOT comprehensive. This training does not take the place of reading the policy and procedure manual and terms and conditions of individual provider agreements/contracts. 3 Provider Enrollment Review Effective February 1, 2013 the SCDHHS implemented the following changes to FQHCs enrollment claims criteria: Changes were made with the implementation of new Medicaid provider enrollment and screening regulations, as published by the Centers for Medicare and Medicaid Services (CMS). 4 2
Provider Enrollment (Cont.) To be in compliance, FQHCs are required to enroll all clinical staff rendering services to SC Medicaid beneficiaries. Clinical staff will need to be linked to each individual FQHC group number to meet claims submission criteria. 5 Provider Enrollment (Cont.) The NPI # of the referring and rendering provider must be included on the Medicaid claim form for payment. The referring provider is the individual who directed the patient for care. 6 3
Provider Enrollment (Cont.) The rendering provider is the individual who provided care to the patient. Please refer to the Medicaid Bulletin dated December 14, 2012 for additional information regarding Fee- For-Service beneficiaries. 7 Provider Enrollment (Cont.) For beneficiaries enrolled in a Managed Care Organization (MCO), please refer to the individual MCO plan. For additional questions regarding these changes, please contact the PSC at 1-888-289-0709. 8 4
Policy and Procedures 9 Billing for Behavioral Health Services For Medicaid patients ages 21 and older, Psychiatric Diagnostic Evaluation with medical services is included in the 12 allowed ambulatory care visits per year. For a psychiatric assessment visit bill using procedure code T1015. 10 5
Billing for Behavioral Health Services Beneficiaries under the age of 21 are exempt from this limitation. Medical Evaluation and Management codes are considered medical visits and are counted against the ambulatory visits. 11 Billing for Behavioral Health Services To be reimbursed for additional ambulatory visits over the 12-visit limit, providers must submit a letter directly to DHHS, Behavioral Health, (Asst. Director) requesting additional visits. All requests must state the medical necessity for services, complete with diagnosis, CPT Code, and clinical documentation. The approval must be submitted with the claim. 12 6
Billing for Behavioral Health Services Psychotherapy encounters are billed using Procedure Code T1015 with a modifier 0HE. Additional mental health encounters over 12 maximum allowed, require prior authorization (PA) from the SCDHHS designated QIO (KePRO). 13 BH Services (Cont.) To request a PA, the physician, APRN, or Nonphysician practitioner must complete the DHHS Mental Health Form and submit to the QIO with a cover memo. The submission must include clinical documentation such as a screening tool, assessment, and/or individual care plans that validate the need for extended services. 14 7
BH Services (Cont.) Requests for approval can be faxed to KePRO at 855-300-0082 KePRO Customer Service Phone is 855-326-5219 15 Questions For BH Boot Camp 16 8
Questions For BH Q: Medicare does not allow the LPC to bill as a Medicare recognized clinician as a face to face provider. How can we bill the encounter to Medicaid? As a Medicare denial, with a 1 in the TPL field? A: Yes, you will need to maintain the denial in the clinical record. You are still responsible for reporting the TPL allowance and balance due information on the claim. 17 Questions For BH Q: Visits billed under the MD and NP for medical reasons/follow-up such as assessment/diagnosis. Does this require a referral? Statement of medical necessity? A: No since you are evaluating and diagnosing the beneficiary. This service is billed using procedure code T1015. 18 9
Questions For BH Q: We have tried to request 99213 from KePRO and they have stated they do not authorize. This implies that these services are medical. A: KePRO does not approve E & M codes. KePRO authorizes psychotherapy encounters. 19 Questions For BH Q: Are there documentation requirements beyond the office visit requirements when billing 90792 billed using a T1015? A: Documentation should be appropriate to justify the service including nature of the complaint, illness, history, physical findings, diagnosis and prescribed treatment. 20 10
In closing and FYI DHHS is presently reviewing all BH policy related to MH Parity and if needed, will revise policy accordingly. Thank you for your participation in the Medicaid Program! 21 Questions 22 11