Last September, CMS published a Medicare Learning Network brochure on mental health services.

Included in this brochure is an informative section discussing same-day billing guidelines. Note: The information in this section, and publication, applies only to the Medicare Fee-For-Service Program, also known as Original Medicare.

According to CMS, integration of the following services is an approach to healthcare that can better address the needs of all individuals, including those with mental health and substance use conditions:

  • Mental healthcare services (which under the Medicare program includes treatment for substance abuse);
  • Alcohol and/or substance (other than tobacco) abuse structured assessment, and intervention services (SBIRT services) billed under Healthcare Common Procedure Coding System (HCPCS) codes G0396 and G0397; and
  • Primary healthcare services.

This is regardless of whether a patient is receiving care in a traditional primary care setting or a specialty mental or substance use healthcare setting.

CMS notes that Medicare Part B pays for reasonable and necessary integrated healthcare services when they are furnished on the same day, to the same patient, by the same professional or a different professional. This is regardless of whether the professionals are in the same or different locations.

The following are recognized as being eligible under Part B to provide diagnostic and/or therapeutic treatment for mental, psychoneurotic, and personality disorders as well as Medicare SBIRT services, to the extent permitted under state law:

  • Physicians (medical doctors and doctors of osteopathy), particularly psychiatrists;
  • Clinical psychologists;
  • Clinical social workers;
  • Clinical nurse specialists;
  • Nurse practitioners;
  • Physician assistants;
  • Certified nurse-midwives; and
  • Independently Practicing Psychologists.

In general, Medicare-covered services are those services that are considered medically reasonable and necessary to the overall diagnosis or treatment of the patient’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:

  • Proper and needed for the diagnosis or treatment of the patient’s medical condition;
  • Furnished for the diagnosis, direct care, and treatment of the patient’s medical condition; and
  • Not mainly for the convenience of the patient, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For more information about the Medicare coverage determination process, visit the CMS website. For every service billed, CMS advises that you must indicate the specific sign, symptom or patient complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment for services without patient symptoms or complaints or specific documentation.

Medicare also pays for multiple mental health services furnished to the same patient on the same day. However, the Medicare program prohibits inappropriate and/or duplicate payment for services furnished on the same day. In general, CMS advises you to consult with your local Medicare Administrative Contractor (MAC) to determine if local or national policies may prevent you from billing for certain services on the same day. To find MAC contact information, refer to the CMS website.

Mental health billing guidelines are complex. Services are often rendered in multiple facilities and locations, and coverage for diagnosis and treatment varies widely. It takes a significant amount of time to learn the guidelines — guidelines that are frequently updated and revised.

PGM Billing is a leading provider of mental health billing services. PGM has a core team of medical billing specialists that work closely with practices to identify problem areas and provide education on appropriate billing practices and procedures.

To learn more about our PGM’s mental health medical billing services, request a free demo today.