Domain: Healthcare & Social Assistance
Question:
A large behavioral health organization has expanded its services significantly over the past year and now employs psychiatrists, nurses, licensed therapists and social workers, while also working with a network of peer counselors and clinical trainees. It services a large number of Medi-Cal patients and wants to make sure it's in compliance with the latest billing procedures in its county of Alameda, especially given an increased focus on fraud from the state government. They want to know: Can they bill for services offered when the patient is not present, like when they work with family support persons? What are the different CPT codes and HCPC codes available for community-based care? To what extent can peer counselors and trainees bill for services? What services are not billable?

Expected points in a correct answer:
States that services may be billed when the patient is not present only when the selected code allows collateral or support person involvement
States that 90791 must not be billed for family only or support person only encounters.
States that H0031 must not be billed for family only or support person only encounters.
States that H0032 must not be billed for family only or support person only encounters.
States that H2017 must not be billed for family only or support person only encounters.
States that T1017 must not be billed for family only or support person only encounters.
States that H2021 must not be billed for family only or support person only encounters.
States that H2011 must not be billed for family only or support person only encounters.
States that documentation for collateral services must accurately describe the service and its relationship to the patient's treatment plan.
States that community based care is primarily billed using HCPCS codes rather than CPT codes.
States that H2000 is used for comprehensive multidisciplinary evaluation.
States that H2011 is used for crisis intervention.
States that T1017 is used for targeted case management.
States that H2017 is used for psychosocial rehabilitation.
States that H2021 is used for community based wraparound services.
States that code selection depends on the service definition.
States that code selection depends on the delivery system.
States that code selection depends on the role of the staff member providing the service.
States that staff billing eligibility is determined by provider credentials.
States that staff billing eligibility is determined by enrollment designation.
States that staff billing eligibility is determined by scope of practice.
States that Certified Peer Support Specialists may bill only H0025 and H0038.
States that H0050 is limited to DMC ODS (for Certified Peer Support Specialists)
States that clinical trainees may bill within discipline specific code sets following SPA-23-0026.
States that trainee billing under SPA-23-0026 requires trainee designation to be documented.
States that trainee billing under SPA-23-0026 requires supervision requirements to be documented.
States that administrative and clerical activities are not billable.
States that scheduling is not billable.
States that emails are not billable.
States that incident reports are not billable.
States that court letters are not billable.
States that services provided to individuals other than the patient are not billable.
States that billing a different code to bypass role or service limitations is non-compliant.
States that codes requiring patient presence (such as 90791, H0031, H0032, H2017, T1017, H2021, H2011) require patient presence as a condition for billing.
States that H0050 is limited to DMC ODS (Drug Medi-Cal Organized Delivery System).