Provider Notice issued 06/30/05

To: Participating Community Mental Health Providers

Date: June 30, 2005

Re: Mental Health Procedure Code and Modifier Issues

This notice contains important billing changes. Please review these changes to help ensure continued valid claim submissions.

Invalid HCPCS Code T1052 – Medication Administration

Medication administration code T1052 was incorrectly reported on the service definition and activity crosswalks for both the SASS Program and the Department of Human Services (DHS) Community Mental Health Services program. The second and third digits were transposed. This code should have been identified as T1502.

The incorrect code T1052 will be closed effective for dates of service on and after July 1, 2005. If this code is billed for a service date on or after July 1, 2005, it will reject.

Code T1502 will be made valid retroactive to dates of service beginning August 1, 2004. Providers should immediately begin using the correct code, T1502.

CPT Code T1016 and HO Modifier – Rate Correction

Case management code T1016 (case management – transition, linkage and aftercare) with modifier HO is identified in the Children’s Mental Health Procedure Codes Listing on the Department of Public Aid’s (DPA) Web site with rates of $71.52 (on-site) and $79.44 (off-site) per quarter-hour. These rates are incorrect. The rates should be $17.88 and $19.86 per quarter-hour, respectively. The department is currently in the process of identifying any overpayments made. Affected providers will be notified in the near future. This procedure code and modifier combination was also missing in its entirety from the SASS Program Service Definition and Activity Crosswalk and has been added.

CPT Code 90862 - Pharmacologic Management and Use of Modifiers

Effective immediately, CPT code 90862 will require one of the following modifiers, if a physician does not perform the service:

• Modifier SA – This modifier denotes a service performed by an advanced practice nurse (APN).
• Modifier 52 – This modifier denotes a service performed by non-physician, non-APN staff.

If a physician does not perform the service, you must use one of the modifiers with the procedure code when submitting a claim. This applies to all billings for CPT 90862 with a date of service on or after July 1, 2004.

CPT code 90862 is only payable by Medicare Part B if a physician provides the service. Medicare does not pay for this procedure if a non-physician provides the service. If the patient is Medicare Part B eligible, and a physician performs the service, you must submit a claim to Medicare Part B prior to billing the Department of Public Aid (DPA) or the Department of Human Services (DHS), as applicable. The claim submitted to DPA or DHS must contain the Medicare Part B payment information, or it will reject. If a non-physician performs the service, a claim does not have to be submitted to Medicare first, but the claim sent to DPA or DHS must include the appropriate modifier to denote who performed the service.

Recently, DPA’s Third Party Liability section mailed letters to community mental health providers indicating that the provider must bill Medicare Part B for this code. Given that Medicare Part B only covers this procedure when performed by a physician, some of the letters were sent in error. If the service was not Medicare-covered because a physician did not perform it, the provider should notify the department’s TPL section that no benefit recovery should be attempted. For future claims, the use of the modifiers with procedure code 90862 will assist the Third Party Liability section in identifying appropriate Medicare Part B third party responsibility.

The applicable coding and rate changes contained in this notice are identified in the revised Community Mental Health Services Service Definition and Activity Crosswalk, on the Department of Human Services’ Web site at http://www.dhs.state.il.us/revisedRule132/ and in the SASS Program Service Definition and Activity Crosswalk and the Children’s Mental Health Procedure Codes Listing, located on the Department of Public Aid’s Web site at:

                                            www.illinois.gov/hfs                 

Effective July 1, 2005, the name of the Department of Public Aid (DPA) will change to Healthcare and Family Services, HFS for short. You will soon see the new name on forms, letters and the Internet. Until existing form supplies are exhausted, however, we will continue to use materials bearing the former DPA name and logo. Either version of documents should be considered official regardless of the department name they bear.

Only our name will change. HFS’s programs, staff, office locations, mailing addresses and phone numbers will remain the same as DPA’s. After July 1, you may access information for Healthcare and Family Services (HFS) at: http://www.hfs.illinois.gov

We believe our new name more clearly reflects our mission of service to the State of Illinois including providing access to health care for over 2 million Illinoisans. In our work, we deeply appreciate your participation in our programs. We hope this change poses no inconvenience or confusion for you.

Questions regarding this notice should be directed to the following areas:

• General questions on mental health services codes can be directed to DHS, Division of Mental Health at 217-782-6470.
• Questions relating to correspondence from DPA’s Third Party Liability section can be directed to 217-557-4323.

Anne Marie Murphy, Ph.D.
Administrator
Division of Medical Programs