Question Oregon Medicaid - Prolonged Service Codes for Behavioral Health E/M Services (99417 and G2212)

[sandikoch44]

I am looking for insight from others who provide behavioral health services in Oregon.

• Oregon Medicaid’s behavioral health fee schedule does not list prolonged service codes 99417 and G2212 as covered services.
• However, for E/M codes the medical-dental fee schedule is used for rates, and these prolonged service codes are on the medical-dental fee schedule.
• When we bill 99417 to OHA, we receive denial CO 96 – Non-covered service.
• We have been paid occasionally by some of the CCOs.
• Both prolonged service codes appear on the prioritized list for mental health diagnoses.

Has anyone successfully received payment for 99417 or G2212 when billing Oregon Medicaid for behavioral health services? If so, how are you submitting these claims?

Any guidance or shared experience would be greatly appreciated!

 

[Trish Brayton]

This depends on the primary code you are reporting with the prolonged service codes which only apply to E/M codes such as 99205, 99215 and do not apply to the psychiatric diagnostic evaluation (90791/90792), psychotherapy codes (e.g. 90832, 90833, etc.) or the Health Behavior codes (e.g. 96156, 96158, etc.) which are considered a type of per day type of code per Medicaid NCCI Edits (source link: https://www.cms.gov/files/document/medicaid-ncci-policy-manual-2024-chapter-11.pdf). Oregon Medicaid Medical-Dental Services Fee Schedule shows payment for both, but neither appear on the Behavioral Health Fee schedule (source link: https://www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx). Many of the OR Medicaid CCOs (e.g. CareOregon, Pacific Source, etc.) do specify which one they prefer and some require chart notes to accompany the claim in order to process the prolonged service codes when billing the G2212 (source link: https://pacificsource.com/sites/def... Management Visits and Prolonged Services.pdf). Hopefully this give you a starting point at least.