Wiki T1016 - Case management

[cmedina969800]

Hey all, I am having a hard time with two situations I've been presented with. I have a therapist who wants to bill case management and I'm not confident that these situations qualify so I'm reaching out for thoughts or if someone has a resource they can share.

1st situation- Therapist spent 8 minutes reviewing the client's intake questionnaire and noted follow-up questions for the client's initial biopsychosocial assessment, as well as scoring and interpreting the results of the psychometric assessment. He did this the same day as the actual intake appt. Does that qualify for case management?

2nd situation- The therapist spent approximately 10 minutes with a therapist in the same practice trying to see if he can secure a spot for couples therapy for this client and their partner. He secured a spot with a therapist, but it didn't work with the clients schedule. The therapist reached out to the same therapist to ask to put them on her waitlist so when a spot becomes available that will align the couple can see the other therapist.

Thoughts?

 

[CBLENNIE]

Are these services being billed for Medicaid patients as this is from the code set "National T Codes Established for State Medicaid Agencies"? I ask because most commercial insurance companies don't cover this code and it is not covered for Medicare.

With respect to your scenarios below are my thoughts.

#1. No this doesn't qualify as case management. The review of the intake forms and documenting any follow up items are part of the intake process and are typically included in the appointment services. I'm guessing that in this scenario your provider is probably providing the services described by 90791 and that is the code being submitted to the payer. Encoder Pro's long description of this service is below:​

​

A psychiatric diagnostic evaluation is performed, which includes the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations. Interviews and communication with family members or other sources are included in these codes.​

#2. This might qualify as case management as described below by T1016; however, the code is time based, per 15 minutes, and it is unclear in the coding guidelines whether or not this is a code that can be billed if it meets at least 50% of the time requirement or if the full 15 minutes must be provided in order to bill the service. You will probably need to confirm with any of the carriers you want to bill this service to about their time requirements for billing this code.​

I work for an insurance company and have a background in auditing and payment integrity reviews. For commercial insurance plans this type if inquiry is setting of my spidy senses. It seems like this provider is attempting to bill for services that are typically included in the standard treatment protocol for behavioral health patients and looking to unbundle services to receive additional reimbursement.

For scenario #1 it would be considered bundled to the appointment that the patient filled out the intake paperwork for and we would consider it inappropriate to bill for review of the intake forms separately. This would be the case for both commercial and our dual eligible members who have Medicaid coverage.

For scenario #2 it would be questionable as to whether our commercial policies would cover this service in the situation you've described. For our dual eligible members, we would expect more services than just trying to refer a patient to another therapist in the practice to qualify as case management billable with T1016. So, this service may or may not be covered for our dual eligible members depending on what is documented in the record, and we would expect that the full 15-minute time threshold be met for it to be billable.

Sorry my response isn't straight forward but the coverage of this code is dependent on too many factors to give you absolute yes or no responses.

 

[hellosprout]

Hi Christina,

If you are billing OHP for case management, one of our CCOs provides a .pdf explaining (generally) what is and is not case management, I've included it here. This is for CareOregon but it should apply to OHP more broadly. I send this to therapists when they have questions.

 

[cmedina969800]

Are these services being billed for Medicaid patients as this is from the code set "National T Codes Established for State Medicaid Agencies"? I ask because most commercial insurance companies don't cover this code and it is not covered for Medicare.

With respect to your scenarios below are my thoughts.

#1. No this doesn't qualify as case management. The review of the intake forms and documenting any follow up items are part of the intake process and are typically included in the appointment services. I'm guessing that in this scenario your provider is probably providing the services described by 90791 and that is the code being submitted to the payer. Encoder Pro's long description of this service is below:​

​

A psychiatric diagnostic evaluation is performed, which includes the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations. Interviews and communication with family members or other sources are included in these codes.​

#2. This might qualify as case management as described below by T1016; however, the code is time based, per 15 minutes, and it is unclear in the coding guidelines whether or not this is a code that can be billed if it meets at least 50% of the time requirement or if the full 15 minutes must be provided in order to bill the service. You will probably need to confirm with any of the carriers you want to bill this service to about their time requirements for billing this code.​

I work for an insurance company and have a background in auditing and payment integrity reviews. For commercial insurance plans this type if inquiry is setting of my spidy senses. It seems like this provider is attempting to bill for services that are typically included in the standard treatment protocol for behavioral health patients and looking to unbundle services to receive additional reimbursement.

For scenario #1 it would be considered bundled to the appointment that the patient filled out the intake paperwork for and we would consider it inappropriate to bill for review of the intake forms separately. This would be the case for both commercial and our dual eligible members who have Medicaid coverage.

For scenario #2 it would be questionable as to whether our commercial policies would cover this service in the situation you've described. For our dual eligible members, we would expect more services than just trying to refer a patient to another therapist in the practice to qualify as case management billable with T1016. So, this service may or may not be covered for our dual eligible members depending on what is documented in the record, and we would expect that the full 15-minute time threshold be met for it to be billable.

Sorry my response isn't straight forward but the coverage of this code is dependent on too many factors to give you absolute yes or no responses.

Thank you so much for this. I really appreciate the insight. I was almost confident on scenario #1 that it did not qualify. Scenario #2- still seems a little gray area. But yes, both of these situations are for medicaid members.

With Gratitude,

Christina

 

[cmedina969800]

Hi Christina,

If you are billing OHP for case management, one of our CCOs provides a .pdf explaining (generally) what is and is not case management, I've included it here. This is for CareOregon but it should apply to OHP more broadly. I send this to therapists when they have questions.

Thank you for this! This really simplifies it and since it is Oregon this will help validate and support my reasoning.

With gratitude,

Christina