I am providing you with couple pieces of information that are the basis for our decision as an MCO to not recognize the 96152 code. Attached is an excerpt from the Behavioral Health Databook that governs our covered services, as established by NC DMA. The 96152 code is not included in that table.
The second reference is a recapitulation of the June 2010 Medicaid Bulletin which references the services that fall under the original waiver pilot (Cardinal Innovation, f.k.a. Piedmont Cardinal, PBH).
Note that while 96152 is referenced, it is only included when provided by a Psychiatrist. As a Licensed Psychologist, you would not be considered an eligible provider of this service to the MCO(s).
I would advise you to confer with Dr. Bennett or others to determine if there is an option for you to bill secondary claims to NC DMA via CSC for the dual eligible consumers that you referenced, as this is a non-covered service with SMC.
Thank you for your consideration.
From June 2010 Medicaid Bulletin
Attention: All Providers
N.C. Mental Health, Developmental Disabilities, and Substance Abuse
Services Health Plan Waiver (Formerly, Piedmont Cardinal Health Plan)
Effective July 1, 2010, additional services will be added to the N.C. Mental Health, Developmental Disabilities
and Substance Abuse Services (MH/DD/SAS) Health Plan Waiver. The MH/DD/SAS Health Plan currently
operates in Cabarrus, Davidson, Rowan, Stanly, and Union counties and is administered by the area Local
Management Entity, Piedmont Behavioral Healthcare (PBH). Except for emergency services, all MH/DD/SAS
providers must obtain prior authorization from PBH to qualify for reimbursement of services provided to
Medicaid recipients who, for Medicaid purposes, are residents of the PBH five-county catchment area.
The services listed in the table below will be included in the MH/DD/SAS Health Plan beginning with dates of
service July 1, 2010, when
· the service is provided by a psychiatrist;
· the Medicaid recipient is a resident, for Medicaid purposes, of the PBH catchment area; and
· the Medicaid recipient’s primary diagnosis is in the 290 through 319 range.
If the conditions listed above are met, psychiatrists must obtain prior authorization from PBH to qualify for
reimbursement for these services.
Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes
Evaluation of Implanted Neurostimulator
95970 95971 95972 95973
95974 95975 95978 95979
Standardized Cognitive Performance Testing
96150 96151 96152
Outpatient and Other Visits
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Facility Observation Visits: Initial and Discharge
99217 99218 99219 99220
Inpatient Hospital Visits: Initial and Subsequent
99223 99231 99232 99233
Observation/Inpatient Visits: Admitted/Discharged
99234 99235 99236
Inpatient Hospital Discharge Services
99241 99242 99243 99244 99245
99251 99252 99253 99254 99255
Emergency Department Visits
99281 99282 99283 99284 99285
Nursing Facility Visits
99304 99305 99306 99307 99308
99309 99310 99315 99316 99318
Domiciliary Care, Rest Home, Assisted Living Visits
99321 99325 99326 99327 99328
99334 99335 99336 99337
Care Plan Oversight: Domiciliary Care, Rest Home, Assisted Living and Home
99341 99342 99343 99344 99345
99347 99348 99349 99350
Prolonged Services Outside Customary Services
99354 99355 99356 99357 99358 99359
Alcohol and/or Substance Abuse Structured Screening
96372 96373 96374 96375 96379
Telehealth Originating Site Facility Fee
All services provided in emergency rooms to Medicaid recipients residing in the PBH catchment area with a
primary diagnosis in the 290 through 319 range will be included in the MH/DD/SAS Health Plan beginning with
dates of service July 1, 2010. Providers of emergency room services must contact PBH for reimbursement.
These services are currently billed under the following revenue codes:
RC450 RC451 RC452 RC456 RC459
Behavioral Health and Waiver
Paul Tax, Claims Director
Smoky Mountain Center
828.586.5501 x. 1170
From: Marsha Hammond,PhD [mailto:firstname.lastname@example.org]
Sent: Thursday, August 08, 2013 10:16 AM
To: Paul Tax; Sonia Eldridge; Brian Ingraham
Cc: Bert Bennett
Subject: (cont'd) re: 96152 coding wrap-around
I am sorry, Mr. Tax. The e mail that you just received fired off before I could finish it. Please discard that as it is incomplete. Below is that e mail finished up. thank you.
Marsha V. Hammond, PhD, Licensed Psychologist, NC
RE: MEDICARE code 96152 which wrapped around to NC Medicaid psychotherapy code e.g., 90806, etc.
Thank you for contacting me. I KNOW that 96152 is not in my SMC contract. It has NEVER been a Medicaid code. It is a Health & Behavior code, put into use by the American Psychological Association in conjunction w/ discussions w/ CMS in 2000. I have used it for years without the issues that are plaguing me as associated w/ SMC LME.
If I could turn up my old Medicaid RA's, which are now unavailable as Value Options no longer manages any part of NC Medicaid, via the NC webclaims site, I could print them out and send them to you. I do not keep my RA's from previous years.
As I stated before, prior to the LME's taking over Medicaid, this is what would happen when I submitted a 96152 MEDICARE code for dually eligible clients. NOTE: This is not what took place re: MEDICAID ONLY clients. For those clients, I would simply go to NC Medicaid webclaims, submit the (then) 90806 or whatever applicable code and be paid.
NC MEDICAID VALUE OPTIONS AUTOMATICALLY WRAPPED AROUND for the dually eligible Medicare/ Medicaid clients utilizing the 96152 Medicare code. HOWEVER, a different psychotherapy code was applied. I never asked why. I simply got paid.
I have contacted as per this e mail Dr. Bert Bennett of NC Medicaid, a psychologist working in Raleigh w/ Behavioral Health to see if he can advise you about this matter. I have no idea how to contact Value Options and reobtain my RA's so you understand that this is how things occurred for years prior to the LME's taking over NC Medicaid.
96152 is the most appropriate code for me to use as I interface w/ physicians, psychiatrists, etc., to provide integrated care for my patients who commonly have overlapping medical and mental health issues.
I left you a voice mail a moment ago. Thank you for continuing to look into this matter.