• 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. 

There are two specific modifiers that are used with the T1016:

• HO: Case management by a 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.

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.

UNITS

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes.  For any single timed CPT code in the same day measured in 15 minutes units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.  To encounter/bill subsequent units of the service, the provider must spend at last one half of the billing unit for the subsequent units to be encounter/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. 

The above AHCCCS guidelines match the CMS guidelines for appropriate rounding of units. 

Below is how many minutes are billed for each unit:

1. Service is performed for less than 8 minutes - no units can be billed.

2. Service performed for 8 minutes to 22 minutes  - 1 unit should be billed.

3. Service performed for 23 minutes to 37 minutes - 2 units should be billed.

4. Service performed for 38 minutes to 53 minutes - 3 units should be billed.

5. And so on.   

 Billing limit is 48 units per day.

Please refer to the AHCCCS Behavioral Health Covered Behavioral Health Services Guide under Section I.F.B.10 for complete information regarding units.    

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.

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:  Same provider staff within the same agency - different times in the day:  

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 1 unit. 

SCENARIO 3:  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 1 unit.   
 

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.