Billing

  1. If a consumer with both Medicare and Medicaid was provided a community mental health service that could not be reported/billed to Medicare, can that service be reported, billed and reimbursed through Rule 132 if the pre-service, staff and other requirements were met? (example: Case management-mental health provided by an RSA.)

    Answer: Emphasizing that Medicaid is payer of last resort, if Medicare won't pay for the service and it qualifies under Rule 132, and was provided to a Medicaid-eligible person who has a completed MHA and ITP that include the specific service at the time it is provided then Medicaid can be billed.

  2. When corresponding with a hearing impaired consumer by e-mail for status/case management or even therapy. Is this a billable service?

    Answer: No. There is no provision in Rule 132 for services to be provided via email. Services, per rule, can be provided face-to-face, by telephone or with video conferencing. Please see rule for the limitations by service.

  3. A consumer account representative with a high school diploma, who is not an RSA, MHP or QMHP provides a face-to-face service such as "Fee Assessment" during the initial appointment with a consumer to determine client payor source such as gathering financial information and demographics, which takes about 15 minutes prior to seeing a clinician to start their MHA. Is this a billable service? Could this be under CM-Mental health?

    Answer: No. For any service to be claimed, it must be provided to an eligible client, it must be provided by a qualified staff, and it must be a rule 132 service. Fee assessment is not a rule 132 service.

  4. Staff are not required to use the exact wording of "on-site" or "off-site" if they are saying things in the body of the note such as: spoke with client by phone; received a phone call from client; met with client at home for family session; or, met with client at school for meeting. This would suffice as location without using the exact lingo (on-site, off-site) as long as it was contained in the body of the note, and we didn't have multiple on-site locations. Is this Correct?

    Answer: This is acceptable.

  5. We have several certified sites; most of them are residential group homes, however, we have one that is an office where clients receive services occasionally. Is this considered on-site or off-site since it is not the client's residential home site?

    Answer: On-site and off-site are not determined by client's traveling. It is determined by staff location. If you have an office at a site that houses staff, that site must be certified and services provided there are on-site.

  6. We also have a home which is not agency controlled where we go into the clients home to provide services, is this off-site or on-site?

    Answer: If staff are not housed there, it is off-site.

  7. What is the definition of 'housed"? We have CILA sites in which the agency owns and are certified which have an office, company phone line, computer, etc where we have staff come in and work daily. The home in which we provide services to the clients in their home does not have an office, company phone, however we do have staff that go there and work eight hour shifts. Is that considered staff to be housed there?

    Answer: If that is the regular workplace for those staff, and it sounds like it is, then services they provide should be billed as on-site and the site should be certified.

  8. I am confused as to whether a service provided in a car is on-site or off-site. We have billed off-site regardless of destination. The Collaborative told us that services provided while traveling to a site other than the agency are off-site and services provided while traveling to the agency are on-site. Please clarify.

    Answer: Since you didn't specify what services were being provided and if there was a consumer in the car, I'd start with reminding you that all services provided by telephone, regardless of where the telephone is located, are on-site. Otherwise, the rule states that on-site is service provided in a certified provider site and in the surrounding provider owned, leased or controlled property and buildings and adjacent parking areas."

  9. I need clarification on doctor service for a Medicaid consumer. A psychiatrist meets with the consumer and provides psychiatric evaluation or psychotropic medication monitoring. The consumer does not have a MHA or ITP and/or the MHA or ITP has expired. Is this a billable service by the doctor? In the Service Definition and Reimbursement Guide under Psychotropic medication monitoring, it states that it is a Pre-service requirement for the consumer to have MHA and ITP. And what about Psychiatric evaluation?

    Answer: A physician may always bill directly to HFS for physician services to a Medicaid eligible recipient according to HFS requirements. However, in order to bill for a 132 service, there must be a current MHA and ITP that contain the service.

  10. Is there any clarification about using the 10 and 13 codes for crisis billing? Is one code for assessment and one for intervention? Both are listed on the Service Delivery and Reimbursement Guide, with no delineation.

    Answer: Activity code 10 is for community-based crisis; activity code 13 is for state operated facility pre-screening and referral.

  11. What is the time frame for submitting billing?

    Answer: Bills should be submitted as frequently as possible to ensure timely processing, and no later than 180 days after the date of service.

  12. If MEDICARE is primary and MEDICAID is secondary in a case, 1) Can an agency bill State/Medicaid after they get paid by MEDICARE for the portion not covered by MEDICARE?

    Answer: Yes, they would bill Medicare first and then bill Medicaid for the difference. This is a third party liability claim so the agency would have to indicate the amount paid by Medicare on the claim. They may not bill Medicare and then bill Medicaid for the full Medicaid rate on top of what Medicare paid. (2/22/11)

  13. If we offer a free WRAP orientation and consumers from several providers attend, can each provider bill for the session?

    Answer: When a free WRAP orientation is held for the community, there is no specific Rule 132 service provided to any specific consumer. Therefore, this is not a billable service. (6/1/12)

  14. Do we need to be certified to bill 0 - 3 mental health services under Rule 132? And, is there a different list of acceptable diagnoses for these services?

    Answer: All providers that bill for Rule 132 services must be certified to do so. DMH has only one all inclusive diagnosis list. (6/1/12)

  15. We are currently providing telepsychiatry. When Rule 132 allows service to be provided via video conferencing, how do we bill for the staff person in the room with the client while the person on the other end is providing the service?

    Answer: All Rule 132 requirements apply to services regardless of the method of delivery. If done via video conferencing or telemedicine site, there must still be the provision of a 132 service by a staff person of the certified provider and all documentation requirements must be followed. (9/1/12)

  16. If we provide family therapy/counseling in a group situation to clients who are all members of the same family, can we bill family therapy/counseling individual for each of the clients for the full time of the session?

    Answer: No. You may not bill for more time in an individual session than was actually delivered. This may be billed as family therapy/counseling group for each of the three clients. (9/1/12)

  17. Can we contract with another organization that is not rule 132 certified to provide mental health services in local schools and bill for these services under our certification.

    Answer: No, you may not. All providers that provide Rule 132 services must be certified. (12/1/12)

  18. It has been a common practice to "bundle" case management services, i.e., 5 minutes on 3 occasions during the same day billed as one 15 minute period of service provision?

    Answer: As you have described it, this is not allowable. Individual units of a service may be "rolled up" into one claim as long as the services have the: Same procedure code, Same date of service, Same level of care modifier, Same license level modifier, Same place of service, and Same staff level of qualification in the claim note field. If any of these requirements are not met, a separate unique claim must be submitted. (12/1/12)

  19. What is the difference between "rolled up" and "bundled"?

    Answer: Rolled up is allowed to facilitate billing for numerous incidents of the same service provision during a day. Bundled, which is not allowed, is gathering shorter than 1/2 units into a billable unit. (12/1/12)

  20. Are the start and stop time and signatures for each brief service required in each note where services are rolled up?

    Answer: Yes. Notes must be maintained for the provision of each incident of a service even if the separate units are rolled up for billing. (12/1/12)

  21. Are there any billing issues related to providing community support-group, group therapy/counseling and individual therapy/counseling on the same day to the same client?
    Answer: There are no problems with billing multiple services for the same client on the same day as long as the time periods do not overlap, and, of course, as long as the service is medically necessary and according to the client's assessed needs as detailed in the treatment plan. (6/1/13)
  22. For billing of services provided in 1/4 hour increments, may service time be rounded up?
    Answer: A unit of service may be rounded up only after the provision of at least 7.5 minutes over the previous 15 minute increment of service. (6/1/13)
  23. If individual therapy/counseling is provided to a client and then family begins to participate, how is this billed? Must it be billed as individual and also, separately, as family therapy/counseling? 
    Answer: Bill the service as the service it primarily is. (12.1.13)