CPT T1016, T1017 - Targeted case Managment services

CPT Code Definition

T1016 Case management, each 15 minutes
T1017 Targeted case management, each 15 minutes


DESCRIPTION OF SERVICES

Targeted case management (TCM) programs are available to assist participants with gaining access to the full range of available mental health services, as well as to any needed medical, social, financial, counseling, educational, housing, and other supportive services needed in order to maintain stability in the community.  TCM is available to adults, as well as children and adolescents. Each population must meet the state of Maryland’s medical necessity criteria for TCM services. Adult TCM services offer two levels of service intensity depending on the needs of the participant.

TCM providers will need to clearly articulate the requested intensity of services and rationale when entering authorization requests in ProviderConnect. Child and adolescent TCM (also known as care coordination services) providers have three levels of intensity to select depending on the needs of the participant. Child and adolescent TCM providers need to clearly articulate the requested intensity and rationale when entering authorization requests in Provider Connect.

SERVICE RULES

The TCM service provider is expected to exchange information and coordinate care with the participant’s PCP and other treatment (i.e. substance use disorder treatment, therapist, psychiatrist, etc.) providers when clinically appropriate and with consent when required.   One unit of TCM service for an adult is any service provided on any given date of service where the contact is a minimum of one hour of either face-to-face contact with the participant or contacts with stakeholders and service providers on behalf of the participant. The level of TCM services is based on the severity of the participant's mental illness (Please see Section 7.21 for more information). 


**Adult Level I (Adult General) TCM has a maximum of two units of service per month.  

**Adult Level II (Adult Intensive) TCM has a maximum of five units of service per month.  

One unit of service for a child or adolescent TCM is any service provided on any given date of service where the contact is a minimum of 15 minutes of face-to-face contact with the participant, the minor’s parent/guardian, or contacts with stakeholders and service providers on behalf of the participant. The level of TCM services is based on the severity of the participant's mental illness (Please see Section 7.20 for more information).

**Child and adolescent, Level I (General) TCM has maximum of 12 units of service per month.  A minimum of two units of face-to-face contacts with the participant are required. 

**Child and adolescent Level II (Moderate) TCM services have a maximum of 30 units per month and a minimum of four units of face-to-face contact with the participant. 

**Child and adolescent Level III (Intensive) TCM services have a maximum of 60 units per month. A minimum of six units of face-to-face contact with the participant are required.

For child and adolescent Level I and Level II TCM services, four additional units of service above and beyond the monthly maximum may be billed during the first month of service to the participant and every six months thereafter to allow for comprehensive assessment and reassessment of the participant.

A unit of service for telephonic contact for a child and adolescent TCM participant may not be reimbursed unless the provider has delivered at least eight minutes of service.



REIMBURSEMENT POLICY Mental Health-Targeted Case Management Services

Mental  Health-Targeted Case Management  (MH-TCM) services help adults with a serious and persistent mental  illness (SPMI) and children with a severe emotional disturbance (SED) gain access to needed medical, social, educational, vocational, financial and other necessary services as they relate to the recipient’s   mental  health needs. Coverage is a health plan responsi  bility  for Blue Plus® Minnesota Health Care Program (MHCP) groups.

Policy Statement

MH-TCM services are eligible for Minnesota Health Care Programs (MHCP) subscribers.  

Billing

MH-TCM is   a professional service billed on an 837P cl  aim fo rmat. When billing for MH-TCM,  submit the contracting provider NPI number cu  rrently on file with Blue Plus®. In addition, an individual rendering NPI number is   required when a county contracts   providers to do this   and they bill under a Behavioral Health Clin ic, and individual NPI number is   required on the claim. Without an individual NPI,   cl  aims rej ect as needing one. When a county bills   through a Soci  al Service Agency  , an individual NPI in not needed.

Codes Modifiers Brief Description  Service Limitation

T1017 for HIS/638 and FQHC billing only     HE, HA   Face-to-face encounter (child under age 18 years)       1 unit per encounter

T1017 for HIS/638 and FQHC billing only      HE      Face-to-face encounter (age 18 or older)      1 unit per encounter


CLAIMS PROCESS

**Providers should not submit claims unless the service has been authorized by Beacon 

**Claims should be submitted on a CMS 1500 form.  

**Case management assessment (CPT Code H0031) does not require pre-authorization for adults.  

**Adult TCM is billed as a per day rate (CPT code T1016) **Child and adolescent TCM is billed per unit (CPT code T1017).

**Claims must specify ICD-10 codes, not DSM 5 codes. **Claims for unauthorized services will be denied.


Perinatal Care Coordination

Perinatal care coordination is the process of planning and coordinating care and services to meet individual needs and maximize access to necessary medical, psychosocial, nutritional, educational and other services for the pregnant woman.

Perinatal Care Coordination Service Providers must be a licensed provider in Utah and one of the following qualified providers: 

**  Registered Nurse 
**  Certified Nurse-Midwife  
**  Certified Nurse Practitioner  
**  Social Service Worker 
**  Certified Social Worker 
**  Licensed Practical Nurse who works under the supervision of a registered nurse and has additional training and experience to be a perinatal care coordinator
**  Health Educator must have either a Bachelor’s degree in health education with a minimum of three years’ experience, at least one of which must be in a medical setting, a Master’s degree with a minimum of one year of experience working in a medical setting or with pregnant women, or a Bachelor’s degree and a certificate showing completion of a certification examination in health education.

The service is reported using HCPCS T1017 Targeted Case Management, each 15 minutes.  Limited to four (4) units in a 30-day period.