Institutional claims and Revenue codes for co-occurring disorder claims

crystalp 6 years ago in User Group Help updated by sarah 5 years ago 11

We are new to billing Rule 31 (COD) claims and billing codes H2035 HQ HH and H2035 HH and some of the payers say they require a revenue code of 905 with those codes. I understand rev codes are billed on institutional claims and we currently only bill professional claims, since we are an outpatient clinic. Our clinic directors say we should not bill Institutional claims, since we are not a facility or a residential treatment center. Procentive has told us that some payers require this but it's  hard to wrap our mind around billing a totally different way. We have not worked with the admission field yet and know this is part of institutional claims. Basically, just wondering if anyone else has experience with this? Please help. THank you!


Outpatient clinics can bill on institutional claims - it isn't limited to facilities or residential centers. If that is the requirement for certain payers, then I would follow that process.

The admission field is pretty straightforward, and if you try to bill out a service missing a part of the admission line, Procentive will notify you until you make the correction.

If you are going to bill some payers on a professional claim and some payers on an institutional claim, I would recommend creating duplicates of each codes (just make sure that the rate/code in each payer is set up with the correct codes), then from there it should be pretty straightforward.

Someone might be able to offer a little more insight - but I think that's what would be best.

For the Admissions tab, do ALL of the yellow fields need to be complete? 

Date admitted would be date they entered the CD program, I assume. What about Type, Source, status, facility, etc...all of those really need to be selected appropriately? And if we are billing Institutional claims for past services and lets say the client is no longer actively in the COD program...do the fields in the Admissions tab need to be accurate according to to the date of service (if that makes sense)? Kind of how the payer tab needs to reflect the correct payer info for whatever DOS we are billing out. If we were to bill a DOS from January today, and the client is no longer in the program, would the status in Admissions tab need to be 30 Still patient?


The fields completed depend on the clients status - if you are going to bill a client that has been admitted, treated, and exited the program, you would fill out all fields.

The majority of your fields probably won't change (type, source, facility, program). There are a lot of fields, but remember it is just a one-time set-up per client (and then an update upon discharge, of course).

If a client is still active, we don't put a date discharged, but put a time discharged of (0:00) - I'm not sure if this is necessary or if it just one of those odd quirks we do just because we saw it once and it worked - but it hasn't let us down yet!

For billing a client that has already left, yes you should have the date discharged. I have only had an issue with this once. What this does is determine what the third digit on the "bill type code" will be. If you have a client admitted, serviced, then discharged and send out one batch claim, Procentive logic will choose bill type "1" - admit through discharge claim. Usually this doesn't trip anything up, but I have had a BCBS claim in the past where I needed to fix this number. You can do that by clicking "data" in the "Confirm Invoices", where you can edit the bill type code, then click save, then create the invoice.

Here are the various "third digit" meanings in a bill type code:

0 - Nonpayment or Zero Claims
1 - Admit Through Discharge Claim
2 - Interim (First Claim)
3 - Interim (Continuing Claims)
4 - Interim (Last Claim)
5 - Late Charge Only
7 - Replacement of Prior Claim or Corrected Claim
8 - Void or Cancel of a Prior Claim

If you have any other questions, let me know - I am not familiar with many insurance companies outside of Minnesota's Medicaid and its prepaid payers, but I can try to help out. I know what it's like to bill new services and not have much direction!

Thank you Christopher. I do have more questions. The client I'm working on had a commercial plan for Jan and Feb then got MA starting March 1. I'm currently working on billing the first 2 months to commercial payer (who told us a rev code of 905 is needed). I'm wondering about the bill type code...it defaults to 1 Admit through discharge, however, she continued to receive services after Feb but we will be billing that to MA. Should the bill type code for this first payer in Jan and Feb be one of those other codes? I'm thinking 2 Interim First claim, since it's the first set of claims being sent to this payer but do not sure for sure.

I would try 2 - since they hadn't yet discharged when their payer switched.

Hello - I am currently having an issue with BCBS denying my 1:1 as a duplicate against the group bill out for the day.

Have you had a problem with this?? Everything keeps going to "review" and nothing has been answered yet for me. .... any help is much appreciated! 

It is prohibited by most insurance to bill both group and individual on the same day.  They see the service as a duplicate.

Oh wow really, they seem so different to me. BCBS seems to be the only insurance denying. Even the state is paying for ones sent on the same day. We mainly have PMAP clients  but good to know we may see this more with commercial?Is that mainly who you see it with? 

I've never had an issue with any insruance companies saying that can't bill group and individuals on the same day.  Susan can you show me where it is prohibited to bill

There is not anything to show.  Upon getting denials, we would call and were told that we can not bill both on same day as it is seen as a duplicate service.  Perhaps the rules have changed.  We no longer use the group therapy code.  I would suggest you call your contract managers at each insurance and ask.

We ask that question when we call to confirm coverage for our DBT clients, because a lot of our clients prefer to do their individual and group therapy on the same day. Commercial plans don't cover our IOP DBT program (if they do it is at a much lower rate than is fiscally possible to bill and still sustain our group). Medica PMAP (when they still had it) was the only one that specifically said we could not bill both on the same day, as far as PMAP's go.

Have you tried billing the group service line with a 77 modifier? That would let the payer know it was two different services. It doesn't always work, but on occasion, they will see the difference and pay both. As a general rule, we don't do individual and group on the same day - just to be safe.