Pediatric Behavioral Therapies Billing Manual

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The purpose of this billing manual is to provide policy and billing guidance to providers to obtain reimbursement for behavioral therapy services. This manual is updated periodically to reflect changes in policy and regulations. It applies only to the Health First Colorado Pediatric Behavioral Therapies (PBT) Benefit and does not address services available through other Health First Colorado benefits or any services available through Home and Community-Based Services (HCBS) waiver programs.

Pediatric Behavioral Therapies Benefit Overview

 

Behavioral therapy services are a treatment that helps change maladaptive behaviors. These services must be found to be medically necessary to be covered.

The Pediatric Behavioral Therapies benefit is available to Health First Colorado members who:

All PBT services must be pre-approved in a Prior Authorization Request (PAR) process. Please refer to the Provider Contact web page for the Colorado PAR information.

Additional information about the behavioral health benefit, including eligibility rules for providers, criteria, details about what needs to be included in a prior authorization request, can be found in the Behavioral Therapies Benefit Fact Sheet or Frequently Asked Questions page found on the Pediatric Behavioral Therapies Information web page.

If a member requires support of a medically skilled caregiver to complete a task, such as bathing or hygiene, the associated task shall be considered skilled in nature and covered under other Medicaid state plan benefits. Visit the Home Health web page for more information.

If a member requires assistance with personal care tasks, those services are covered under other Medicaid state plan benefits. Visit the Pediatric Personal care benefit web page for more information.

Co-Treatment Matrix:
The following chart represents co-treatment policy for PBT providers.

  Home Health Therapist Pediatric Behavioral Therapist Outpatient Therapist (Occupational, Physical, and Speech therapists) Home Health CNA Personal Care Provider
Pediatric Behavioral Therapist Allowable only with joint goals in PAR and with approval Allowable with clear reason for safety or medical necessity in PAR and with approval only Providers will only bill for the time interacting with the member, and not the total time in the room. Must have clear, joint goals in PAR and with approval Must provide and document the need for a multi-modality visit, and services must be documented in the care plan – services must be auditable

PBT goals and interventions must be documented in the plan of care with a description of how they are performed with CNA tasks
Must provide and document the need for the multi-modality visit, and services documented in the care plan – services must be auditable

PBT goals and interventions must be documented in the plan of care with a description of how they are performed with PC tasks

Telemedicine and Pediatric Behavioral Therapy:
Pediatric Behavioral Therapists are not listed as a provider type that can bill the facility fee (Q3014) or the GT modifier. However, if the provider believes that providing behavioral therapy via telemedicine is medically appropriate in the situation and within the scope of their license/training, then doing so is allowed. In such cases, providers will not be paid the fee associated with Q3014 or GT modifier.

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Eligible Providers

Organizations with a TAX ID must enroll as type 83 -Behavioral Therapy Clinic.

Eligible individuals are:

  • Psychologist with a doctorate degree-type 37
  • Licensed Behavioral Health Clinician - type 38
  • Behavioral Therapist - type 84

 

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Rendering and Billing Provider Numbers

PBT services must be billed using the 837 Professional (837P) transaction or CMS 1500 form, which requires using rendering and billing National Provider IDs (NPIs).

Each agency’s specific billing number will be used to reimburse the provider.

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Pediatric Behavioral Therapy Benefit Procedure Code Table

Beginning January 1, 2019, the existing Applied Behavioral Analysis procedure codes will be changing with new HCPCS updates. All claims billed for dates of service on or after January 1, 2019 must utilize the new procedure codes listed below.

2018 Procedure Code 2018 Procedure Modifier NEW PROCEDURE CODING 2019 Rate 2019 Unit
H0046   97153 $13.37 Per 15 Minutes
New 2019 97154 $6.69 Per 15 Minutes
H0046 TJ 97155 $20.85 Per 15 Minutes
New 2019 97158 $10.43 Per 15 Minutes
T1024   97151 $307.35 Per Assessment
T1024 TJ 97151 TJ $36.06 Per 30 minutes

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Not Required When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Not Required  
11a. Insured's Date of Birth, Sex Not Required  
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Not Required  
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Not Required  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070115 for July 1, 2015. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Not Required  
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
EPSDT
All dates of service must be the same date as screening.
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
12 Home
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member's physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.

Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
Not Required
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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Pediatric Behavioral Therapy Claim Example

Pediatric Behavioral Therapy Claim Example

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Pediatric Behavioral Therapy Specialty Manual Revisions Log

Revision Date Addition/Changes Made by
8/29/2016 Added new code to code table HCPF
8/17/2017 Added updated codes to table HCPF
10/16/2017 Language Modification HCPF
6/25/2018 Updated billing to point to general manual, removed PAR information (found on general manual) HCPF
6/28/2018 Removed claim submission info that is found in general manual HCPF
8/3/2018 Updated to new format, added co-treatment chart and language modification HCPF
1/4/2019 Updated HCPC codes HCPF
3/18/2019 Clarification to signature requirements HCPF
01/21/2020 Converted to web page HCPF
9/14/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF