Domain: Healthcare & Social Assistance
Question:
An independent outpatient mental health provider is contracting with the Alamda County Department of Health to deliver services to Medi-Cal patients as part of a new program. They're in the process of transitioning over to SmartCare and need to comply with the new billing system as part of the contract. The provider offers community-based services including peer support, individual and family counseling and care coordination to higher-level care. They want to know: What are the changes to billable services after July 1, 2023? How do they code for care delivered in different settings? Which practitioners can bill for services? Are services eligible for reimbursement if they are not direct patient care?

Expected points in a correct answer:
States that InSyst procedure codes were discontinued July 1, 2023.
States that services must be billed using CPT or HCPCS codes after July 1, 2023.
States that the use of CPT and HCPCS codes will depend on the type of service rendered.
States that the use of CPT and HCPCS codes will depend on the qualifications of the rendering provider.
States that CPT codes are used for outpatient clinical services.
States that the use of CPT codes requires the rendering provider to be a licensed clinician who acts within the scope of practice.
States that the use of HCPCS codes are for non-clinical or community based services.
States that the use of HCPCS codes are for services delivered by non-licensed staff.
States that practitioner billing eligibility is determined by their credentials.
States that licensed clinicians may bill CPT codes appropriate to their discipline.
States that non-licensed staff may bill designated HCPCS codes.
States that Certified Peer Support Specialists are limited to peer-specific HCPCS codes.
States that clinical trainees may bill within discipline-specific code sets following CMS approval of SPA 23-0026.
States that trainee billing requires that supervision and trainee designation requirements are met.
States that services must reflect the actual place of care.
States that the services must reflect the actual modality of care.
States that telehealth services require identification of whether delivery was audio-only or audio-video.
States that the telehealth documentation of patient location determines billing validity
States that only direct patient care time is billable.
States that documentation time is not billable.
States that administrative activities are not billable.
States that chart review is not billable.
States that travel time is not billable.
States that some non-billable activities may be reimbursed through a separate contractual invoicing mechanism.
States that practitioner billing eligibility is determined by their scope of practice.
States that practitioner billing eligibility is determined by the provider classification they are enrolled in.
States that whether the patient was present during the telehealth session affects billing validity
Lists examples of licensed clinicians who may bill CPT codes, such as psychiatrists, psychologists, LCSWs, LMFTs, and LPCCs.
States that HCPCS codes used by non-licensed staff are limited to those allowed under the applicable benefit.
States that telehealth billing requires identification of whether the patient was located at home.