BEHAVIORAL HEALTH CODING POLICY

POLICY NUMBER

None

DESCRIPTION

Claims submitted with the Behavioral Health Services listed within this coding policy are required to follow the coding guidelines below or the claim will be rejected. It is important that you share this coding policy with your billing and coding staff to ensure they are aware of the coding updates.  This Behavioral Health Coding Policy is applicable for Blue Cross & Blue Shield of Mississippi’s local insured business, Self-Insured business, Federal Employee Program (FEP), Blue Cross subscribers from another Blue Plan (BlueCard) and for Participants of the Mississippi State & School Employees Health Insurance Plan (Advanced Health Systems).

TYPES OF FACILITIES AND LEVELS OF CARE

“Hospital” is a short-term, acute-care, general hospital which:

1. Is a licensed institution;

2. Provides inpatient services and is compensated by or on behalf of its patients;

3. Provides surgical and medical facilities primarily to diagnose, treat, and care for the injured and sick; except

   th

   at a psychiatric hospital will not be required to have surgical facilities;

4. Has a staff of physicians licensed to practice medicine; and

5. Provides 24-hour nursing care by registered nurses.

“Residential Treatment Center (RTC)” means a specialized level of care health facility providing behavioral health and/or substance use disorder Residential Treatment services. The Residential Treatment Center offers twenty-four (24) hour awake supervision, including at least eight (8) hours a day nursing and twenty-four (24) hours a day nursing availability and psychiatrist visits at least once per week. The staff should include qualified licensed professional counselors, psychiatrists, psychologists, psychotherapists and physicians. The RTC’s licensure may differ somewhat by state, and they are typically designated residential, sub-acute, or intermediate care facilities and may occur in care systems that provide multiple levels of care.  Residential Treatment services will differ in degree of intensity of service [e.g., number of hours and number of times per week] depending on the nature of the disorder and age of the Member. At a minimum, Residential Treatment services must include: psychiatric/medical evaluation; psychosocial/substance use assessment; clinical assessment; toxicology screening; medication reconciliation; medication monitoring; medical history and physical exam; individual/group/family/support/recovery/12-step therapy; structured therapeutic plan/multi-disciplinary plan; psychiatrist/physician visits; nursing staff on site; and, an initial discharge plan.

“Partial Hospitalization Program (PHP)” means treatment other than full twenty-four (24) hour programs in a treatment facility licensed and/or certified by the State of Mississippi and approved by BCBSMS. Partial Hospitalization is a structured, short-term treatment program that offers nursing care and active treatment in a program that operates at a minimum of six (6) hours per day, five (5) days per week. Members must attend a minimum of six hours per day when participating in a Partial Hospitalization Program. Members are not cared for on a 24-hour per day basis, and typically leave the program each evening and/or weekends. Partial Hospitalization Program services are provided by a multidisciplinary treatment team, which includes a licensed behavioral health professional for behavioral health and/or substance use conditions. Partial Hospitalization Program services are an alternative to acute inpatient hospital care or Residential Treatment Center and offer intensive, coordinated, multidisciplinary clinical services for Members that are able to function in the community at a minimally appropriate level and do not present an imminent potential for harm to themselves or others.

“Medical Detoxification” means a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substance of abuse. Medical Detoxification seeks to minimize the physical harm caused by abuse of substances. A physician must certify the treatment as Medically Necessary. The nature and pattern of substance use, including frequency and duration, predicts the potential for clinically significant withdrawal necessitating 24 hour medical intervention to prevent complications and is not appropriate for a lower level of care.

“Intensive Outpatient Program (IOP)” means services provided for Members with an active psychiatric or substance related illness who are able to function in the community at a minimally appropriate level and present no imminent potential for harm to themselves or others. The Members are unresponsive to traditional outpatient services, requiring more intensity of service, and as a step-down from or in lieu of inpatient hospitalization. The Intensive Outpatient Program is a structured short-term treatment program that provides a combination of individual, group and family therapy services. The Intensive Outpatient Program provides a minimum of nine (9) hours of direct services per week. Typically, this is a minimum of three (3) hours per day, three (3) days per week. The Intensive Outpatient Program must be supervised by a licensed behavioral health professional.

“Outpatient Behavioral Health Therapy” means behavioral health services provided in a hospital’s outpatient department, clinic, doctor’s office, or therapist’s office.

POLICY

CLAIM FILING GUIDELINES

INPATIENT TREATMENT

HOSPITAL

One claim should be filed for the entire episode of care.  A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Medical Detoxification services, presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/recovery/12-step therapy, structured therapeutic plan/multi-disciplinary plan, psychiatrist/ physician visits, nursing staff on-site, and an initial discharge plan. 

Interim bills will not be accepted.

Services provided during a Behavioral Health episode of care by medical professionals employed or contracted with the filing facility cannotbe billed separately.

Unrelated medical services (not behavioral health related) that are rendered during an episode of care by the hospital or a provider outside of the hospital can be filed separately. These are other services provided by another Provider and are outside the behavioral health episode of care as defined above.

Inpatient hospital claims should be filed based on the following requirements.

RESIDENTIAL TREATMENT CENTER - ACUTE MEDICAL DETOXIFICATION

One claim should be filed for the entire episode of care. A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Medical Detoxification services, presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/ recovery/12-step therapy, structured therapeutic plan/multi-disciplinary plan, psychiatrist/ physician visits, nursing staff on site, and an initial discharge plan. 

Interim bills will not be accepted.

Services provided during a Behavioral Health episode of care by medical professionals employed or contracted with the facility cannot be billed separately.

Unrelated medical services (non-behavioral health) rendered during an episode of care by a provider outside of the residential treatment center can be filed separately.

Inpatient residential treatment center claims for acute medical detoxification should be filed based on the following requirements.

RESIDENTIAL TREATMENT CENTER

One claim should be filed for the entire episode of care.  A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/ substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/recovery/12-step therapy, structured therapeutic plan/multi-disciplinary plan, psychiatrist/physician visits, nursing staff on site, and an initial discharge plan.

Interim bills will not be accepted.

Services provided during a Behavioral Health episode of care by medical professionals employed by or contracted with the facility cannot be billed separately.

Unrelated medical services (non-behavioral health) rendered during an episode of care by a provider outside of the residential treatment center can be filed separately.

Inpatient residential treatment center claims should be filed based on the following requirements.

OUTPATIENT TREATMENT

PARTIAL HOSPITALIZATION PROGRAM (PHP)

One claim should be filed for the entire episode of care. A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/recovery/12-step therapy, structured therapeutic plan/ multi-disciplinary plan, psychiatrist/physician visits, nursing staff on site, and an initial discharge plan.

Interim bills will be accepted.

Services provided during the PHP treatment period by medical professionals employed or contracted with the facility cannot be billed separately.

Unrelated medical services (non-behavioral health) that are rendered during the PHP treatment period by a provider outside of the facility can be filed separately.

PHP claims should be filed based on the following requirements.

INTENSIVE OUTPATIENT PROGRAM (IOP)

One claim should be filed for the entire episode of care. A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/recovery/12-step therapy, structured therapeutic plan/ multi-disciplinary plan, psychiatrist/physician visits, nursing staff on site, and an initial discharge plan.

Interim bills will be accepted.

Services provided during the IOP treatment period by medical professionals employed or contracted with the facility cannot be billed separately.

Unrelated medical services (non-behavioral health) rendered during the IOP treatment period by a provider outside of the facility can be filed separately.

IOP claims should be filed based on the following requirements.

OUTPATIENT HOSPITAL - BASED BEHAVIORAL HEALTH THERAPY

One claim should be filed for the entire episode of care. A separate claim(s) should not be filed for services included in the episode of care. An episode of care includes the following services provided during the patient’s treatment time period:  Presumptive drug testing, definitive drug testing and any other laboratory procedures, psychiatric/medical evaluation, psychosocial/substance abuse assessment, clinical assessment, medication reconciliation, medication monitoring, medical history and physical exam, individual/group/family/support/recovery/12-step therapy, structured therapeutic plan/ multi-disciplinary plan, psychiatrist/physician visits, nursing staff on site, and an initial discharge plan.

Interim bills will be accepted.

Services provided during a Behavioral Health episode of care by medical professionals employed by or contracted with the facility cannot be billed separately.

Unrelated medical services (non-behavioral health) rendered during the outpatient treatment period by a provider outside of the facility can be filed separately.

Outpatient behavioral health therapy claims should be filed based on the following requirements.

PROFESSIONAL TREATMENT

HOSPITAL

Services provided during an episode of care by medical professionals employed by or contracted with the facility during a hospital (inpatient or outpatient), residential treatment center, acute inpatient medical detoxification, partial hospitalization, or intensive outpatient episode of care cannot be billed separately.

CLINIC/OFFICE-BASED BEHAVIORAL HEALTH THERAPY

Services provided in the clinic/office setting (place of service code 11) by medical professionals can be filed separately on a CMS-1500 claims form using the appropriate CPT/HCPCS procedure and ICD-10 diagnosis codes.

Refer to the Medicine section in the most current CPT code book for a list of procedure codes you should use to bill psychiatric and chemical dependency services in the office. In addition, accordance to current coding guidelines appropriate codes from the Evaluation and Management section along with a timed add-on code for the medical services may also be reported to support services documented in the patient’s medical records. 

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coding guidelines outline in this Coding Policy should not be used in lieu of the Member’s specific benefits plan language.

POLICY HISTORY

12/16/2019: Policy Published

4/29/2020: Policy revised

1/01/2023: Policy revised (Policy revision effective 5/1/2023)

SOURCE(S)

None

CODE REFERENCE

None