CurrentOptumPolicy N/A

CBHC encounter and crisis intervention billing and payment rules

Defines billing, coding, and payment rules for Certified Community Behavioral Health Clinic (CBHC) encounter bundles, component services, non-encounter services, and crisis intervention services for Optum; affects CBHC providers billing Medicaid services.

Policy Summary

PayerOptum

PolicyCBHC encounter and crisis intervention billing and payment rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill T1040 with modifier HB for members aged 21 and over and with modifier HA for members under age 21; include at least one component service code on the claim or the claim will deny.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1T1040 units per member per date

At least 1Component codes required

1S9485 units per member per date

Per 15 minutesH2011 increment

Age 21T1040 modifier age cutoff

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Coverage criteria for CBHC encounter and crisis interventions

Encounter bundle coverage criteria

Conditions required for payment of the CBHC encounter bundle (T1040):

Encounter bundle payable only when ALL of the following are met:

ALL of the following

T1040 billed with modifier HB for members aged 21 and over (age based on date of birth on date of service)
T1040 billed with modifier HA for members under age 21 (age based on date of birth on date of service)
Only one unit of T1040 payable per member per date of service by the same CBHC provider; additional units will be denied
At least one component service code from the listed service codes is billed on the same claim with the T1040 encounter code (component codes will zero-pay when submitted with the encounter); if no component code is included, the claim will deny

Exclusions - services that CANNOT be billed on the same date as the encounter bundle by the same provider

H0015 with TF modifier (Enhanced Structured Outpatient Addiction Program)
S9480 (Intensive Outpatient Program)
H0015 (Structured Outpatient Addiction Program)
If any of these codes are billed on the same date of service as T1040 by the same provider for the same member, the claim submitted first will be processed for payment; subsequent claims will deny.

Component service codes may be submitted for multiple services provided on the same date; all applicable service codes should be included on the claim

Component service codes will 'zero pay' when submitted with the encounter code (T1040)

Crisis intervention coverage criteria

Rules governing S9485 and H2011 crisis intervention billing and payment:

Per-diem crisis code S9485: only one unit payable per member per date of service by the same provider, except for S9485-ET and S9485-HA ET

If multiple units or duplicate claim lines for S9485 are submitted by the same provider for the same date, the plan will pay the first processed claim and deny the second (exception: S9485-ET and S9485-HA ET)

S9485 (except S9485-ET or S9485-HA ET) and H2011 may not be billed on the same date of service by the same provider; if both billed on the same claim it will deny; if billed on separate claims the first processed claim pays and the second denies

S9485 with modifier ET or HA ET (community crisis stabilization) may be billed on the same day as H2011

ALL of the following

Component, encounter, and crisis intervention codes

CBHC component and crisis intervention codesCPTCovered

90791	Psychiatric diagnostic evaluation
90791-HA	Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths)
90792	Psychiatric Diagnostic Evaluation with Medical Services
90832	Psychotherapy, 30 minutes with patient
90833	Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (add-on)
90834	Psychotherapy, 45 minutes with patient
90836	Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (add-on)
90837	Psychotherapy, 60 minutes with patient
90838	Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (add-on)
90839	Psychotherapy for crisis, first 60 minutes

1–10 of 37

1/4

Crisis per-diem variantsCPTCovered

S9485-ET	Crisis intervention per diem, ET variant
S9485-HA ET	Crisis intervention per diem, HA ET variant
S9485-U1	Crisis intervention per diem, U1 community-based variant

Crisis per-15-minute unitsCPTCovered

H2011-HN	Crisis intervention service, per 15 minutes (adult mobile)
H2011-HA	Crisis intervention service, per 15 minutes (youth mobile)

Encounter bundle codeCPTCovered

T1040	CBHC encounter per diem (must be billed with modifier HB for adults 21+ or HA for youth under 21 and at least one component service code)
T1040 HB	Modifier HB for members aged 21 and over
T1040 HA	Modifier HA for members under age 21

Component code requirement

RequirementAt least one component service code must be billed on the same claim with T1040 (plus HA or HB modifier) or the claim will deny.

Zero-payComponent service codes included with the encounter code will 'zero pay' when submitted with T1040.

Multiple componentsMultiple component service codes may be provided and should all be included on the claim for the same date of service.

Billing and provider action requirements

Billing Rule

Encounter billing: T1040 + age modifier; single-unit rule and component code requirement

Bill T1040 with modifier HB for members aged 21 and over and with modifier HA for members under age 21. Only one unit of T1040 will be paid per member per date of service by the same CBHC provider; additional units will be denied. At least one component service code from the listed service codes must be billed with T1040 or the claim will deny.

Use member's date of birth on the date of service to determine age-based modifier.
Component service codes submitted with the encounter code will zero-pay but are required to avoid claim denial.

Key definitions and service distinctions

Encounter bundle definition

DefinitionEncounter bundle = T1040 plus applicable modifier (HB for adults 21+, HA for youth <21) and at least one component service code.

Unit limitOnly one unit of T1040 will be paid per member per date of service by the same CBHC provider; additional units will be denied.

Age-specific billingBill T1040 with modifier HB for members aged 21 and over; bill T1040 with modifier HA for members under age 21; claims will deny if age/ modifier mismatch occurs.

Non-Encounter Bundle Services

DefinitionNon-Encounter Bundle Services are services provided by the CBHC that are billed separately from the outpatient encounter bundle (T1040 + HA or HB) and may be provided and paid on the same date as encounter services.

Examples excluded from encounterCertain codes (H0015 with TF, S9480, H0015) cannot be billed by the same provider on the same date as T1040; the first processed claim pays and subsequent claims will deny.

Billing practiceNon-encounter services should be submitted on separate claim lines as appropriate since they are not part of the T1040 encounter bundle.

Crisis intervention services definition

Included codesCrisis intervention includes per-diem S9485 variants (e.g., S9485-ET, S9485-HA ET, S9485-HE, S9485-U1) and H2011 per-15-minute codes.

S9485 unit limitOnly one unit of S9485 may be payable per member per date of service by the same provider, except for S9485-ET and S9485-HA ET which are exceptions.

Mutual exclusionS9485 (except ET/HA ET) and H2011 may not be billed on the same date of service by the same provider; if both are billed the first processed claim pays and the second denies.

H2011 billing incrementH2011 is billed in 15-minute units; multiple units may be billed in one day and modifiers/POS determine staff level, location, and follow-up allowances.

Place of service and modifiersModifiers and POS control payment rates and designate adult vs. youth and community vs. CBHC-site interventions (e.g., S9485-U1 and H2011 community-based variants require POS 15).