Covered and Noncovered Services : Codes

Modifiers

The following tables list the applicable modifiers that providers are required to use when requesting PA and submitting claims for outpatient mental health services. Not all providers may be reimbursed for all mental health services.

APNPs with a psychiatric specialty and psychiatrists are the only mental health providers who can submit claims for psychotherapy services that include a medical E&M component. Additionally, APNPs with a psychiatric specialty are required to be separately enrolled in Wisconsin Medicaid as a nurse practitioner in order to be reimbursed for an E&M service.

*Physicians can bill for CPT central nervous system assessments/tests procedure codes.

Place of Service Codes

Allowable POS codes for the outpatient mental health benefit are listed in the following table. Note that not all of the POS codes listed in this table are allowable for each procedure code allowed in the outpatient mental health benefit. Providers are required to use the POS code that most accurately describes the place where the service(s) were rendered.

For services provided to members under 21 years of age outside of an office setting, providers are required to document the therapeutic reasons for using an alternative location to support the member's recovery

The outpatient mental health benefit does not include services provided in the home or community settings for members age 21 and over. See the Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults service area for outpatient services covered in the home or community.

Procedure Codes

Nationally recognized procedure codes such as CPT codes are required on all outpatient mental health claims submitted on the 1500 Health Insurance Claim Form. Claims or adjustments received without an appropriate procedure code are denied. The mental health and substance abuse maximum allowable fee schedule indicates maximum allowable fees and copayment rates.

Psychotherapy CPT procedure codes are time-based codes representing 30, 45, and 60 minutes of services. A unit of time has been reached when a provider has completed 51 percent of the designated time. To report psychotherapy, the session time must be at least 16 minutes. The proper procedure code is then selected based on the actual time closest to the time written in the code descriptor. This represents an actual time of 16 to 37 minutes for the 30-minute procedure codes (codes 90832 and 90833), 38 to 52 minutes for the 45-minute procedure codes (codes 90834 and 90836), and 53 minutes or greater for the 60-minute procedure codes (codes 90837 and 90838).

The following table lists the procedure codes and applicable modifiers that providers are required to use when requesting PA and submitting claims for outpatient mental health services. Not all providers may be reimbursed for all mental health services.

Outpatient Mental Health Services Procedure Codes

+ Add on procedure code.
* POS code 12 is allowable only for central nervous system assessments/tests and outpatient mental health services for members under 21 years of age. Services provided in the home (POS code 12) are only reimbursable when billed by a Medicaid-enrolled mental health outpatient clinic.

Independent providers who are able to bill Wisconsin Medicaid directly for outpatient mental health services are required to submit documentation that shows it is appropriate to use an alternative location to support the member's recovery when providing services outside of the provider's office or a school.

The outpatient mental health benefit does not include services provided in the home or community settings for members age 21 and over. See the Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults service area for outpatient services covered in the home or community for members age 21 and over. This benefit is a county-matched benefit.

Inpatient POS codes are not allowable for providers when payment for those services is included in the hospital's Medicaid DRG reimbursement. See the Inpatient Hospital service area for more information on what services are included in the DRG payments.

Unlisted Procedure Codes

According to the HCPCS codebook, if a service is provided that is not accurately described by other HCPCS CPT procedure codes, the service should be reported using an unlisted procedure code.

Before considering using an unlisted, or NOC, procedure code, a provider should determine if there is another more specific code that could be indicated to describe the procedure or service being performed/provided. If there is no more specific code available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered. Submitting the proper documentation, which could include a PA request, may result in more timely claims processing.

Unlisted procedure codes should not be used to request adjusted reimbursement for a procedure for which there is a more specific code available.

Unlisted Codes That Do Not Require Prior Authorization or Additional Supporting Documentation

For a limited group of unlisted procedure codes, ForwardHealth has established specific policies for their use and associated reimbursement. These codes do not require PA or additional documentation to be submitted with the claim. Providers should refer to their service-specific area of the Online Handbook on the ForwardHealth Portal for details about these unlisted codes.

For most unlisted codes, ForwardHealth requires additional documentation.

Unlisted Codes That Require Prior Authorization

Certain unlisted procedure codes require PA. Providers should follow their service-specific PA instructions and documentation requirements for requesting PA. For a list of procedure codes for which ForwardHealth requires PA, refer to the service-specific interactive maximum allowable fee schedule.

In addition to a properly completed PA request, documentation submitted on the service-specific PA attachment or as additional supporting documentation with the PA request should provide the following information:

• Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
• List/justify why other codes are not appropriate.
• Include only relevant documentation.
• Include all required clinical/supporting documentation.

For most situations, once the provider has an approved PA request for the unlisted procedure code, there is no need to submit additional documentation along with the claim.

Unlisted Codes That Do Not Require Prior Authorization

If an unlisted procedure code does not require PA, documentation submitted with the claim to justify use of the unlisted code and to describe the procedure/service rendered must be sufficient to allow ForwardHealth to determine the nature and scope of the procedure and to determine whether or not the procedure is covered and was medically necessary, as defined in Wisconsin Administrative Code.

The documentation submitted should provide the following information related to the unlisted code:

• Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
• List/justify why other codes are not appropriate.
• Include only relevant documentation.

How to Submit Claims and Related Documentation

Claims including an unlisted procedure code and supporting documentation may be submitted to ForwardHealth in the following ways:

• If submitting on paper using the 1500 Health Insurance Claim Form, the provider may do either of the following:
  • Include supporting information/description in Item Number 19 of the claim form.
  • Include supporting documentation on a separate paper attachment. This option should be used if Item Number 19 on the 1500 Health Insurance Claim Form does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in Item Number 19 of the claim form and send the supporting documentation along with the claim form.
• If submitting electronically using DDE on the Portal, PES software, or 837 electronic transactions, the provider may do one of the following:
  • Include supporting documentation in the Notes field. The Notes field is limited to 80 characters.
  • Indicate that supporting documentation will be submitted separately on paper. This option should be used if the Notes field does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in the Notes field of the electronic transaction and submit the supporting documentation on paper.
  • Upload claim attachments via the secure Provider area of the Portal.

Valid Codes Required on Claims

ForwardHealth requires that all codes indicated on claims and PA requests, including diagnosis codes, revenue codes, HCPCS codes, HIPPS codes, and CPT codes be valid codes. Claims received without valid diagnosis codes, revenue codes, and HCPCS, HIPPS, or CPT codes will be denied; PA requests received without valid codes will be returned to the provider. Providers should refer to current national coding and billing manuals for information on valid code sets.

Code Validity

In order for a code to be valid, it must reflect the highest number of required characters as indicated by its national coding and billing manual. If a stakeholder uses a code that is not valid, ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid code.

Code Specificity for Diagnosis

All codes allow a high level of detail for a condition. The level of detail for ICD diagnosis codes is expressed as the level of specificity. In order for a code to be valid, it must reflect the highest level of specificity (that is, contain the highest number of characters) required by the code set. For some codes, this could be as few as three characters. If a stakeholder uses an ICD diagnosis code that is not valid (that is, not to the specific number of characters required), ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid ICD diagnosis code.