Covered and Noncovered Services : Codes

Modifiers

The following tables list the applicable modifiers that providers are required to use when submitting claims for outpatient mental health and substance abuse services in the home or community for adults.

Information is available for DOS before October 1, 2023.

Place of Service Codes

Allowable POS codes for outpatient mental health and substance abuse services in the home or community for adults are listed in the following table.

Procedure Codes

Valid procedure codes and modifiers are required on all claims for outpatient mental health and substance abuse services in the home or community for adults. Claims or adjustments received without a valid procedure code are denied. The mental health and substance abuse maximum allowable fee schedule indicates maximum allowable fees and copayment rates.

The following table lists the valid procedure codes and modifiers that providers are required to use when submitting claims for outpatient mental health and substance abuse services in the home or community for adults. Not all providers may be reimbursed for all mental health and substance abuse services in the home or community for adults.

Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults Procedure Codes

^* Add-on procedure code.

^** Providers are required to indicate modifier U3 in addition to the appropriate professional level modifier and informational modifier when submitting claims for travel time using procedure code 99199.

Inpatient hospital or residential care services: BadgerCare Plus and Wisconsin Medicaid cover "partial hospital" services under a separate benefit—day treatment/day hospital services (Wis. Admin. Code § DHS 107.13[4]).

Substance Abuse Treatment Procedure Codes

^* The list of allowable ICD diagnosis codes for outpatient mental health and substance abuse services in the home or community is inclusive. However, not all Medicaid-covered outpatient mental health and substance abuse services in the home or community are appropriate or allowable.

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.