December 16, 2016
Provider Notice: T1016 - AHCCCS Revised Billing Instructions

AHCCCS has recently revised their guidelines regarding HCPCS code T1016 (case management).  The guidelines will revert back to previous rules. 

 

Case Management (HCPCS code T1016) is a supportive service provided to enhance treatment goals and effectiveness. Activities may include:
  • Assistance in maintaining, monitoring and modifying covered services;
  •  Brief telephone or face-to-face interactions with a person, family or other involved party  for the purpose of maintaining or enhancing a person's functioning;
  •  Assistance in finding necessary resources other than covered services to meet basic needs; 
  •  Communication and coordination of care with the person's family, behavioral and general medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and other State agencies;
  •  Coordination of care activities related to continuity of care between levels of care (e.g., inpatient to outpatient care) and across multiple services (e.g., personal assistant, nursing services and family counseling);
  •  Outreach and follow-up of crisis contacts and missed appointments;
  •  Participation in staffing, case conferences or other meetings with or without the person or their family participating; and
  •  Other activities as needed.
Case management does not include:
  • Administrative functions such as authorization of services and utilization review; or 
  • Other covered services listed in the AHCCCS BEHAVIORAL HEALTH SERVICES Covered Behavioral Health Services Guide.
Additional information can be found in the AHCCCS Behavioral Health Covered Behavioral Health Services Guide  under Section II.D.1 - Case Management.

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.

HCPCS CODES
  • T1016 HO - CASE MANAGEMENT BY BEHAVIORAL HEALTH PROFESSIONAL - OFFICE: Case management services (see general definition above for case management services) provided at the providers work site.
Provider Qualifications: Behavioral Health Professional
Billing Unit: 15 minutes
  • T1016 HO - CASE MANAGEMENT BY BEHAVORAL HEALTH PROFESSIONAL - OUT-OF-OFFICE: Case management services (see general definition above for case management services) provided at a person's place of residence or other out-of-office setting.
Provider Qualifications: Behavioral Health Professional
Billing Unit: 15 minutes 
  • T1016 HN - CASE MANAGEMENT - OFFICE: Case management (see general definition above for case management services) provided at the provider's work site.
Provider Qualifications: Behavioral Health Technician or Behavioral Health Paraprofessional
Billing Unit: 15 minutes
  • T1016 HN - CASE MANAGEMENT - OUT-OF-OFFICE: Case management services (see general definition above for case management services) provided at a person's place of residence or other out-of-office setting.
Provider Qualifications: Behavioral Health Technician or Behavioral Health Paraprofessional
Billing Unit: 15 minutes
The Covered Behavioral Health Services Manual Appendix B-2  (Allowable Procedures Codes and Provider Types) lists the POS available for this code:
  • Office POS: 05, 06, 07, 08, 11, 20, 34, 49, 50, 53, 54, 71, and 72 
  • Out-of-Office POS: 12, 22, 23, 99
The Centers for Medicare and Medicaid Services (CMS) provides a Place of Service Codes for Professional Claims  table that lists POS codes and their descriptions for your convenience.

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.
BILLING LIMITATIONS

For case management services, the following billing limitations apply:
  
1)  Case management services provided by a DLS licensed inpatient, residential or in a therapeutic/medical day program setting are included in the rate for those settings and cannot be billed separately. However, providers other than the inpatient residential facility or day program can bill case management services provided to the person residing in and/or transitioning out of the inpatient or residential settings or who is receiving services in a day program. 

2)  A single provider may not bill case management for any time associated with a therapeutic interaction, nor simultaneously with any other services.

3)  Multiple provider agencies may bill for this service during the same time period when more than one provider is simultaneously providing a case management service (e.g., a staffing). In addition, more than one individual within the same agency may bill for this service (e.g., individuals involved in transitioning a person from a residential level of care to a higher (subacute) or lower (outpatient) level of care), staff from each setting may bill case management when attending a staffing.

4)  Billing for case management is limited to individual providers who are directly involved with service provision to the person (e.g., when a clinical team comprised of multiple providers, physicians, nurses, etc., meet to discuss current case plans).

5)  Transportation provided to a Mercy Maricopa enrolled member is not included in the rate and should be billed separately using the appropriate transportation procedure codes.

6)  For case management codes: 
  • See general core billing limitations in Section I.
  • Where applicable, travel time by the provider is included in the rates. See core provider travel billing limitations in Section I.
  • The provider should bill all time he/she spent in direct or indirect contact with the person, family and/or other parties involved in implementing the treatment/service plan. Indirect contact includes telephone calls, picking up and delivering medications, and/or collateral contact with the person, family and/or other involved parties.
  • Written electronic communication (e-mail) and leaving voice messages are allowable as case management functions. These functions are not to become the predominant means of providing case management services and require specific documentation as specified below.
  • Written electronic communication (e-mail) must be about a specific individual and is allowable as case management, as long as documentation (a paper copy of the e-mail) exists in the case record.
  • When voice messages are used, the case manager must have sufficient documentation justifying a case management service was actually provided. Leaving a name and number asking for a return call is not sufficient to bill case management. 
  • When leaving voice messages, a signed document in the client chart granting permission to leave specific information is required.
7)  When a provider is picking up and dropping off medications for more than one behavioral health recipient, the provider must divide up the time spent and bill the appropriate case management code for each involved behavioral health recipient.

8)  In accordance with other case management restrictions, Mercy Maricopa is permitted to encounter behavioral health case management for services provided within 60 days of planned discharge from the Arizona State Hospital for the purposes of coordinating care between inpatient and outpatient providers.

As always, don't hesitate to contact your Provider Relations Liaison with any questions or comments. You can find this notice and all other provider notices posted on our website .

Thanks for all you do!

  
 

 





Copyright © 2014. All Rights Reserved.