Electronic Billing & EDI Transactions
The information in this section is intended for the use of health care providers, clearinghouses and billing services that submit transactions to or receive transactions from Medicare fee-for-service contractors. EDI is the automated transfer of data in a specific format following specific data content rules between a health care provider and Medicare, or between Medicare and another health care plan. In some cases, that transfer may take place with the assistance of a clearinghouse or billing service that represents a provider of health care or another payer. EDI transactions are transferred via computer either to or from Medicare. Through use of EDI, both Medicare and health care providers can process transactions faster and at a lower cost. Please see pages on specific types of EDI conducted by Medicare for related links and downloads as applicable.
Medicare Coding & Billing
New Physical Therapy Evaluation and Reevaluation CPT Codes PTs must begin using 3 new evaluation codes and a new reevaluation code beginning January 1, 2017. Now is the time to become familiar with them.
Medicare Fee, Payment, Procedure code, ICD, Denial
Interv hlth/behav fam no pt Coverage Indications, Limitations, and/or Medical Necessity Indications The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria: The patient has an underlying physical illness or injury, and There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and The assessment is not duplicative of other provider assessments In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient’s capacity to understand and cooperate with the medical interventions necessary to their health and well being. Health and Behavioral Intervention (with the family and patient present) (CPT code 96154) is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient. Limitations Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who: Does not have an underlying physical illness or injury, or For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or Does not have the capacity to understand and to respond meaningfully during the face to face encounter, because of: Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective. Delirium Severe and profound mental retardation Persistent vegetative state/no discernible consciousness, Impaired mental status, e.g., Disorientation to person, time, place, purpose, or Inability to recall current season, location of own room, names and faces, or Inability to recall that he or she is in a nursing home or skilled nursing facility, or Does not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, or For whom the conditions noted under the indications portion of this section are not met. Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT code 96155. Examples of Health and Behavioral Intervention services not considered reasonable and necessary and not covered are: Provide family psychotherapy or mediation Maintain the patient’s or family’s existing health and overall well-being Provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions. Individual social activities Teaching social interaction skills Socialization in a group setting Vocational or religious advice Tobacco or caffeine withdrawal support Teaching the patient simple self-care Weight loss management Maintenance of behavioral logs Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP-Specialty Code 68). Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention. Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 999x