Date: November 1, 2022
To: Enrolled Encounter Rate Clinics, Federally Qualified Health Centers, and Rural Health Clinics
Re: Change in Billing for Behavioral Health Encounters Effective December 1, 2022
This notice informs Encounter Rate Clinics (ERCs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs) of a billing change to identify behavioral health encounters, effective with dates of service beginning December 1, 2022. This change applies to claims billed under Medicaid fee-for-service (FFS) and HealthChoice Illinois (HCI) managed care organization (MCO) plans.
Currently, providers use procedure code T1015 - Clinic Visit/Encounter, All-Inclusive, to bill both medical and behavioral health encounters rendered in FQHCs, ERCs, and RHCs, with behavioral health encounters being differentiated by use of one of the modifiers below:
Modifier AJ = Licensed Clinical Social Worker
Modifier AH = Licensed Clinical Psychologist
Modifier HO = Licensed Clinical Professional Counselor or Licensed Marriage and Family Therapist
To conform with the Centers for Medicare & Medicaid Services' (CMS) Medically Unlikely Edits (MUEs) policy for T1015, which does not allow for both a medical and a behavioral health encounter to be billed on the same day without exception approval from CMS, the Department of Healthcare and Family Services (HFS) is changing the encounter procedure code to identify behavioral health services rendered in ERCs, FQHCs, and RHCs.
Effective with dates of service beginning December 1, 2022, providers must use procedure code T1040 - Medicaid Certified Community Behavioral Health Clinic Services, Per Diem, instead of T1015, for billing behavioral health encounters within ERCs, FQHCs, and RHCs. Providers must continue to utilize the modifiers above, and behavioral health encounter reimbursement will remain at current rates.
Providers who bill T1015 with a behavioral health modifier for dates of service on or after December 1, 2022, will receive the following error code:
- P03 – Provider Not Enrolled for Category of Service/Date of Service
FQHCs and RHCs can bill services using procedure code T1015 with no modifier and T1040 with an applicable behavioral health modifier for the same customer, same date of service.
ERCs can bill services for a customer using procedure code T1015 with no modifier and T1040 with an applicable behavioral health modifier but not for the same date of service. Encounter rate clinic payment policy does not allow billing of both a medical encounter and a behavioral health encounter on the same date.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the applicable HCI MCO plan.
Kelly Cunningham, Administrator
Division of Medical Programs