Here’s an update on how we’re processing behavioral health claims

In previous Record articles and web-DENIS messages, we told you about the American Medical Association’s release of new procedures codes, effective Jan. 1, 2013. Since then, we’ve made some system changes to support AMA requirements.

Here’s an update on how we’re currently managing behavioral health claims:

• Some codes have been replaced with new codes. For example, *90804 (outpatient psychotherapy, 20-30 minutes) is replaced with *90832 (psychotherapy, 30 minutes).
• Some codes that were previously "bundled" to include both evaluation and management services, along with therapy services, have been unbundled. So E&M with therapy services now may require the use of more than one code. For example, *90807 (outpatient psychotherapy with E&M services, 45-50 minutes) has been replace with *90836 (45 minutes, psychotherapy add-on) and an appropriate E&M base code. The E&M code must meet appropriateness of service.

Procedure code *90862 for pharmacologic management was end-dated and now evaluation and management codes can be billed in its place. To address this, we temporarily allowed procedure code M0064 to replace code *90862.

However, effective Aug. 1, 2014, we will no longer allow M0064 to be reimbursed. Instead, an appropriate E&M code must be billed.

How members are affected
The revised AMA procedure codes also affect Blue Cross members. We’ve highlighted below the changes members might experience.

• Evaluation and management services can be billed with either a primary medical or primary behavioral health diagnosis code and will be processed according to the member’s benefits. For example, if an E&M procedure code is billed with a behavioral health diagnosis, the claim will be processed against the member’s behavioral health cost share.

Because of these changes, members’ cost-sharing responsibilities may have changed between 2013 and 2014.

Keep the following guidelines in mind:

• A member who receives services for both therapy and evaluation and management will only have one copay.
• If a member’s group has its behavioral health benefits carved out, these services now must be processed by the group’s third-party vendor. The voucher will identify who should be billed.

If you have any questions, contact your provider consultant.