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Cavalier40

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We have an outpatient SA facility in Florida. We have been billing regular outpatient group therapy under rev code 0915 on the UB04. Florida Blue is now telling us that 0914 and 0915 are not reimbursable codes as of 6/1/15 and they never should have been. I am at a loss on how to alternatively bill this service. Any advice?
 
Cavalier40 said:
We have an outpatient SA facility in Florida. We have been billing regular outpatient group therapy under rev code 0915 on the UB04. Florida Blue is now telling us that 0914 and 0915 are not reimbursable codes as of 6/1/15 and they never should have been. I am at a loss on how to alternatively bill this service. Any advice?
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Cavalier40,

Have you found the resolution to this matter?
 
No progress as of yet. Claims reps will tell you that you have to get a 5 digit provider number to submit the claims on a 1500 form. However when you ask if a single provider can have both a 3 digit and 5 digit provider number (I am sure they cannot) They get confused.

One of my billers did get through to a coding specialist at Fl Blue, however they were trying to say that DCF does not give licenses for regular OP treatment when they clearly do.

I did call New Directions and they were confused about it as well. I pretty much asked them how can I get prior authorization for outpatient services through a blue card home plan, and have no way to bill it to the host plan? They told me I would get a call back, but it is now a week later and nothing yet.

One thing I did think of is billing the correct CPT under rev code 0961, but I could not find out anything.

On a side note I find it funny that they are defining 0912 as SA and 0913 as MH PHP, when the NUCC classifies them as less/more intensive PHP for both SA and MH while at the same time linking the NUCC on their website.
 
Hopefully this helps.....See attachment...(Had a local FL BLUE rep send me)


Have you thought about billing as a Behavioral Health Outpatient Clinic Group?..Is this something a facility can do?..... I pulled this from FL BLUEs site:

Behavioral Health Outpatient Clinic Groups
Behavioral Health Outpatient Clinic (BHOC) groups are comprised of outpatient clinics that provide professional services performed by Licensed Clinical Social Workers (LCSWs), Behavioral Analyst Doctorate (BCAD), Board Certified Behavioral Analyst (BCBA), Board Certified Assistant Behavioral Analyst (BCaBA), Licensed Marriage and Family Therapists (LMFT), Licensed Mental Health Counselor (LMHC), associated with Psychiatric and Substance Abuse (PSA) facilities and Community Mental Health Centers (CMHC).

All services provided by the BHOC group in the PSA facility or CMHC will be applied to the member?s total outpatient visits. Benefits for the BHOC groups match the benefits applied to behavioral health professionals.

Providers participating in the New Directions Behavioral Health network should follow billing guidelines as instructed by New Directions via their website at www.ndbh.com. If there are any questions, New Directions can be contacted by phone at 1-888-611-6285.

Billing Requirements
BHOCs should be billing with place of service ?11?.

The Facility?s NPI number should be placed in block 24J and in block 33a. The individual rendering master level clinician NPI number is not needed for these claims.

IMPORTANT: LMHC and LMFT license types are excluded from seeing Medicare members.
 

Attachments

  • +19545121680-0924-161257-167.pdf
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Thank you for the info, however its just confirming the situation.

1500 forms cannot be used by a facility. If a 1500 form is filed and you only have a 3 digit provider number with Fl Blue, then the claim will not be accepted. Claims reps will tell you that you need a 5 digit provider number (professional services). However since the provider number is attached to the TIN of the facility or medical group and the configuration of the provider number has to do with the type of facility or practice (SA providers are 3 digit alpha-numeric numbers starting with "S") my assumption is that you cannot have both a 3 digit and 5 digit provider number at the same time.

It seems to me that they want us to open a completely separate practice. Now we do also operate a professional services group for ancillary services, however I am not thinking its acceptable to bill to that group, even though our clinical directors and medical director are part of the group. Reason being is that DCF allows those at the IOP and OP levels of care to attend groups together. Why would I bill one person as if they were visiting a facility and the next person in the same group as if there were having an office visit. Also when I receive prior auth from the home plan for ASAM level I care, it is usually done as a continuum of care as a step down from IOP. Finally it is our facilities that are licensed to perform outpatient substance abuse care, not our medical group.

This is a complete cluster bleep.

The more research I do I think this may not be just a FL thing, but a New Directions things. This would also effect AL, AR, KS and MI. The New Directions provider manual has pretty much the same language as the BCBS manual.
 
Social Workers

You all sound very knowledgeable about social workers. I am just trying to figure out how they can Bill. If you could look at my thread from Pulmonary and advise me I would really appriciate it. I sent the post yesterday Oct. 15th. thank you
 
Hello there!

We are experiencing the same thing. Currently we changed the rev code to 0911 and they began paying for it with the 90853 however we just got a letter this week that they have caught on to our 0911 rev code and adding it to the list of 0914 and 0915. A facility can not have a 3 digit and a 5 digit provider number. Only professional Doctors can. Currently we are pending provider update. Our MD has a 5 digit provider number and is registered with FL BCBS we sent in a provider update form to add our location (facility address with NPI ) which they will add to the 5 digit provider number. BTW this takes 90 days to update. We are sitting ducks right now just waiting for this to happen. Once approved I will bill on a 1500 with the md as the provider but the location of services will be the facility . This is a faster way to remedy having to start a separate practice with a tax npi and register as professional. Hope this helps!
 
Luckily our facility had a separate professional services group in which we bill for our ancillary services and labs. I have began billing 90853 on the 1500 and have been getting paid, group still has the OON allowed of $75 per session (based on FL Blue OON allowed). Since the CPT does not specify length, I wonder if we can bill more than 1 in a day.

My other issue is home plans giving facility prior auths for groups. How can I get a prior auth for a specific level of facility care, but the home plan not allow to bill for that level of care.
 
That is good. I am still waiting for the approval for my location attached to my MD's 5 digit provider number . I am glad your getting paid.

Now your other issue with a specific level of care being authorized and denying these services as not payable of course is ridiculous. Is it stating that group services is covered on the VOB (verification of benefits) ? I would use that as the fight that when called and verified it was a covered service. Sometimes my UR person advises them of the codes being billed and sometimes they note it on the authorization and sometimes it is driven by DX and placed under a board umbrella of Inpatient or Outpatient services so when billed it is pays by whatever code falls under in or outpatient. Hope this helps.
 
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