CMH Clinical Care Conultation

We have not started to bill this code yet, but the rate is published on the Mental Health Codes and Maximum Adjusted FFS rate schedule. There are several different rates based on time.

Thanks so much!

We have been using it for DOS back to 2-25-15 now. History of being paid for it: spotty! Please make sure all your documentation is in order, because some carriers are asking for it.

Is this only an MHCP code or is it reimbursed by commercial plans? Are you using this for CTSS? I've been told is also gets used for SFT (county programs). Is anyone doing it with SFT? Thanks!

Hi Kim, I am still having problems getting reimbursed by some commercial carriers. But I think they are starting to come along--I was just reimbursed by BCBSMN for a 90899 from August 2015. Best of luck to you!

Thanks Sheryl! Did you appeal the denial in this case?

Yes. DAP notes were sent to BCBS in December, and we were just finally paid on May 31st. Persevere! :)

Sheryl, out of curiosity, what was paid for the 90899? I know rates differ among clinics/doctors, etc. and how long was the service/ amount of units if it's billed with more than 1 unit?

Crystal, it was between 11-20 minutes, by phone. (U4, U9 was billed). BCBS reimbursed $41.25. Do you have the list of modifiers for the 90899?

No, I do not. If you do can you share them? Thanks again.

Clinical Care Consultation: 90899(HN if applicable)

In-person

U8 (5-10 min)

U9 (11-20 min)

UB (21-30 min)

UC (30+ min)

Phone

U8 U4 (5-10 min)

U9 U4 (11-20 min)

UB U4 (21-30 min)

UC U4 (30+ min)

Great information. Thanks Sheryl!

So, here it is July now and I JUST got paid for another 90899 by BCBS, again dating to August 2015. Just to remind everyone that persistence pays!

Hi Sheryl,

Our facility is interested in billing this CPT code 90899. I have a couple of questions for you.

1) What do you charge for this code?

2) Which payers are paying the code?

3) Does this code require a prior authorization prior to billing?

Thank you,

Debbie Trunk

Hi Debbie,

1) What do you charge for this code?  I've been charging about 3X what we are paid.  For in-person, that is 35.00, 73.00, 121.00 and 192.00.  For phone consult, that is 27.00, 54.00, 91.00 and 144.00.

2) Which payers are paying the code?  We've been paid by MA and PrimeWest consistently.  Haven't billed to South Country or Blue Plus.  We have been paid by BCBS commercial sometimes, but have regularly had to appeal their initial decision.  We got paid for it once by Health Partners, but I was told later this should not have happened, as it's their policy to only pay for face-to-face with the client or family.   I hope as commercial carriers see more of this, they start to recognize its value to our mutual clients.  

3) Does this code require a prior authorization prior to billing?  Above 15 hours per calendar year, you will need authorization.  Here is a link to the MHCP page with more information:

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_198190

Hope this helps, Debbie!

Sheryl

Thank you Sheryl. Your comments are very helpful. One more question with regard to the Non-Face to Face services. We are to use the modifier U4 along with the Code 90899. Is this time based or we use this combination irregardless of time? 

I would need to create 4 CPT Codes 90899 for the face to face service using modifiers: U8; U9; UB; UC.  If we were to use the Non-Face to Face, I would only need to create one code - 90899 U4?

Debbie Trunk

Debbie,

You would need 8 CPT's.  See below:

Clinical Care Consultation: 90899(HN if applicable)

In-person

U8 (5-10 min)

U9 (11-20 min)

UB (21-30 min)

UC (30+ min)

Phone

U8 U4 (5-10 min)

U9 U4 (11-20 min)

UB U4 (21-30 min)

UC U4 (30+ min)

So the time modifiers are the same for both phone and in-person.  The U4 modifier is used with all the phone consultations.

Got it. Yes. I realized I needed 8 codes after I sent the message

Do you have any idea what the allowed amount might be?

Debbie

I have a few ranges:  U8 U4 is reimbursed between $11.67 and $12.48.  U9 U4 between 22.94 and 24.11.  UB U4 between 38.41 and 40.43.  UC face to face 65.13 to 88.00.  

Perfect. Again, I appreciate your time with your responses. Each one of them were very supportive.

Thank you again Sheryl. 

Debbie

You are most welcome, Debbie!

Sheryl

I'm curious how you have this 90899 code set-up in Procentive. Do I need each different time increment as well as in-person or phone, set-up as a different code with it's corresponding modifier or is there a way to make just one code and list the modifiers out? Then too is it set-up as always billing 1 unit or is this where the different time increments come into play? Uhhh! Help. Thanks!

HELP! Would the above referenced list of codes become 8 different/separate codes in Procentive?

yes, these would be entered as separate codes.

Good news about the Clinical Care Consultation: I just got an EOB for BCBS MN and they paid a 90899 without me having to appeal and fight for it! Good luck, all, keep billing them!

Was a pre-authorization required for BCBS? It looks like MA requires it but not sure about the commercial carriers..

No pre-authorization was required for BCBS and MA only requires authorization when the client reaches the threshold of 15 hours per calendar year. For MA, since we don't report exact minutes, they count the upper limit of time on the care consultation. So if your consultation was 21 minutes, they will count 30 minutes toward the threshold. Hope this helps!

Yes, thank you!

I have had to send our notes to BCBS every time. HP is also starting to require documentation. Even the PMAP's are difficult about it. I think because it's a new code. How did you get BCBS to pay without needing to submit additional information, Sheryl?

Sarah, just to clarify- you bill the 90899, get a denial saying more documentation is necessary and then send in the documentation to get paid. Is that what is happening?

Yes. That is exactly how it is happening.

Sarah, this was the first time they've paid without additional documentation. Perhaps they have seen it enough now to know what it is.

Your lips to God's ears, right? I hope that is what it is. It seemed as though they thought it was an anesthesia code of some sort, at first.

Something interesting to note: the MHCP Provider Manual says that the child must have a dx that meets the definition of complex as defined in the MN Rules 9505.0372, Subpart 1 or co-occurs with other complex and chronic health conditions. The MN Rule says:

An extended diagnostic assessment must include a face-to-face interview with the client and contain a written evaluation of a client by a mental health professional or practitioner working under clinical supervision as a clinical trainee according to part 9505.0371, subpart 5, item C. The face-to-face interview is conducted over three or more assessment appointments because the client's complex needs necessitate significant additional assessment time. Complex needs are those caused by acuity of psychotic disorder; cognitive or neurocognitive impairment; need to consider past diagnoses and determine their current applicability; co-occurring substance abuse use disorder; or disruptive or changing environments, communication barriers, or cultural considerations as documented in the assessment.

Interesting. I am going to have our Program Director look at that. Thank you!

How are you handling PreferredOne as a primary payer, with MA as secondary? PreferredOne denies at the Clearinghouse, which doesn't allow us to bill MA. Billing MA directly results in them denying for not billing the primary. I have a work order open (for the third time as people at DHS keep closing them without resolution) on this topic, but am not getting any response from DHS. I have emailed and called, but have not had any progress. Does anyone know of a modifier or anything that will allow us to bill secondary payers due to no coverage with primary payers? Thank you, in advance, for your help!

I have tried for four years to figure out how to do this and I always run into walls. It never works. The only way may be that the client has to send in the claim to Primary themselves and get denied and then send the denial to their secondary.

All I can do on my end is to keep nagging those primary payers about the value of the clinical care consultation.  In hopes that someday they will possibly add it to their covered services.  I've had a few appeals approved, but more denied.  One recent denial (HP) told me they don't cover anything that's not face-to-face with the client and/or family.  It will be tough for us all--best of luck!  

Sheryl

Thank you for your feedback Sheryl. I am going to keep trying with DHS, to be able to submit directly to them for items like these, that will not process through the primary payer. It is so frustrating to have a service that DHS DOES pay for, get denied by them, especially when we are doing things correctly. I will let you know if I get anywhere in my fight.

Thanks, Sarah, yes it is frustrating.  I, too, will let you know if I get anywhere.

Hello all, has anyone had any luck billing the 90899 codes to NGS?

Thanks, Sara

I believe we were paid for one.  Because we were in the middle of changing to EFT's and ERA's, the documentation got dropped on it.  But because I only have one Tricare client and because of the payment amount, I believe it was for the 90899.  Good luck!

Sheryl

Hey Sheryl, I've been trying to get paid by NGS, unsuccessfully. First I was told that Medicare Part B does not recognize the modifiers, in this case U9 and U4. Rep told me to remove the modifiers and send a new claim. Denied again, same carc code, 4. New rep said I need to submit a more detailed narrative and perhaps include specific documentation proving that the billed claim was medically necessary. Do you know what you have for the narrative description and are you sending any additional documentation?

I have "Consult support system" in the Payer tab, Rates sub tab, Code sub tab for the narrative description, fyi.

I haven't had any trouble getting paid with the originally billed codes (with the modifiers) from most pmap plans, commercial payer different story. I don't think they've really begun to pay this code too much as of yet.

Thanks for any insight, Sara

Just curious what people are using for documentation for the clinical care consults? Do the clinicians utilize the contact log or progress note? Thanks, Sara

We have a Clinical Care Consultation note that our staff use. I'm sure it was something Procentive had that they made available to us. Send Forms a ticket - I'm sure they can make one available to you.

Okay, thanks Sarah. Do you attach it to your service line much like a regular PN?

Yes, we do.