Case Management (T1016) is a supportive service provided to enhance treatment goals and effectiveness. It can include a brief telephone or face-to-face interaction for the purpose of maintaining or enhancing a person's functioning. Case management does not include administrative functions such as authorization of services and utilization review. Additional information can be found in the
Covered Behavioral Health Services Guide
.
There are two specific modifiers that are used with the T1016:
HO: Case management by a licensed master's or higher degree level Behavioral Health Professional (Office or Out of Office)
HN: Case management services provided by an unlicensed bachelor's or higher level degree behavioral health technician or behavioral health paraprofessional (Office or Out of Office)
Office or Out of Office is determined by the Place of Service (POS) documented in the member's record and on the claim form.
Office POS: 05, 06, 07, 08, 11, 20, 34, 49, 50, 53, 54, 71, and 72
Out-of-Office: 12, 22, 23, 99
The following is a link to the Centers for Medicare and Medicaid Services (CMS) POS table that lists POS codes and their descriptions:
BILLING
NPI
HO modifier can be billed under the NPI of the individual licensed Behavioral Health Professional or the facility's NPI as the rendering provider.
HN modifier must be billed under the NPI of the facility's NPI as the rendering provider.
UNITS
T1016 is a 15 minute, per unit code. For services with billing units of 15 minutes, the first unit of service can be encountered/billed when 1 or more minutes are spent providing the service. To encounter/bill subsequent units of the service, the provider must spend at least one half of the billing unit for the subsequent units to be encountered/billed. If less than one half of the subsequent billing unit is spent providing the service, then only the initial unit of service can be encountered/billed. Since it is difficult to do 7.5 minutes, records are audited on the "8 minute rule". Claims should be billed based on the below.
1-22 minutes = 1 unit,
23-37 minutes =2 units,
38-52 minutes = 3 units,
53-67 minutes = 4 units and so on.....
If different provider staff within the same agency is rendering the services (as documented in the member's record) then separate T1016 should be billed on different claim forms.
Billing limit is 48 units per day.
SCENARIO 1: Two provider staff within the same agency at different levels
Jane Doe (Behavioral Health Professional - HO modifier) sees Member A for case management services on May 25, 2016 from 9:00 - 9:10
Jack Smith (Behavioral Health Technician - HN modifier) sees Member A for case management services on May 25, 2016 from 11:00 - 11:11
Two claim forms with the appropriate modifier should be submitted with a billing of 1 unit each.
SCENARIO 2: Two provider staff within the same agency at the same level
Jane Doe (Behavioral Health Professional - HO modifier) sees Member A for case management services on May 25, 2016 from 9:00 - 9:10
Joan Smith (Behavioral Health Professional - HO modifier) sees Member A for case management services on May 25, 2016 from 11:00 - 11:11
One claim form should be billed BUT 2 units should be billed since they are different provider staff.
SCENARIO 3: Same provider staff within the same agency - different times in the day (at least 15 minutes between each service)
Jane Doe (Behavioral Health Paraprofessional - HN modifier) sees Member A for case management services on May 25, 2016 from 9:00 - 9:10 ( 10 minutes), and 12:00 - 12:13 (3 minutes) and then again from 3:00 - 3:05 (5 minutes)
One claim form should be submitted with 3 units
SCENARIO 4: Same provider staff within the same agency - continuous (less than 15 minutes between each service)
Jane Doe (Behavioral Health Paraprofessional - HN modifier) sees Member A for case management services on May 25, 2016 from 9 -9:15 (15 minutes), from 9:25-9:29 (4 minutes), and from 9:35-9:40 (5 minutes)
One claim form would be billed with 2 units (total time spent providing case management is 24 minutes)
SCENARIO 5: Two different paraprofessional provider staff within the same agency) - THIS WOULD BE BILLED ON ONE CLAIM FORM UNDER THE FACILITY NPI
Jane Doe (Behavioral Health Paraprofessional - HN modifier) sees Member A for case management services on May 25, 2016 from 9 -9:15 (15 minutes)
John Smith, (Behavioral Health Paraprofessional - HN modifier) sees Member A for case management on May 25, 2016 from 11:00- 11:05 (5 minutes)
One claim form would be billed with 2 units (since they are different providers)
