Same Day Billing Clarification Provided by CMS – Welcome Resource for Behavioral Health Integration

Date: 

12/05/2013

Integrated Behavioral Health and Primary Care providers have encountered a barrier due to regulations and systems that have prevented certain services from being billed together on the same day.  The Center for Medicare and Medicaid Services (CMS) has recently issued welcomed clarification on this matter about Medicare payment.

Medicare’s Fee-for-Service Program, also known as Original Medicare, provides same-day billing for integrated mental health, alcohol and substance abuse, and primary care health services that better address the needs of individuals, especially those with mental health and substance use conditions. The American Medical Association (AMA) has created a fact sheet detailing information on same-day billing guidelines imposed by the National Correct Coding Initiative (NCCI), and a list of other relevant resources pertaining to Medicare’s Fee-for Service Program.

When necessary, integrated health care services addressing mental health, alcohol or substance use assessments and interventions, and primary health care services are provided on the same day to a patient. Medicare Part B will cover the cost regardless of whether services are provided by the same provider or multiple providers and without regard to whether or not the multiple providers are co-located. Eligible providers include physicians, clinical psychologists or social workers, nurse practitioners, physician assistants, certified nurse-midwives, and independent practicing psychologists.

To receive coverage by Medicare, the health services must meet the medical criteria defined by National Coverage Determinations, Local Coverage Determinations, and qualify as “necessary” services. To be deemed necessary, the services must meet standards of good medical practice and be 1) needed for the diagnosis or treatment of a condition, 2) specific to the treatment and care of a patient’s medical condition, and 3) not out of convenience for the patient, provider, or supplier. For all services billed to Medicare, documentation must be provided listing patient signs and symptoms necessitating the service. Although the NCCI enforces national coding and payment methods that prevent certain services from being billed together on the same day, Medicare will pay for multiple mental health services provided to a patient in the same day, as long as they are distinct and warranted.

More information on Medicare coverage determination processes, NCCI procedures, and same-day billing publications can be found in AMA’s fact sheet at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Same-Day-Billing-Text-Only-Fact-Sheet-ICN908978.pdf .