Temporary Clinical Policy Modifications: Payment for Healthy Opportunities Screening and Referral

<p>Effective&nbsp;Jan.&nbsp;1, 2021, NC Medicaid and NC Health Choice are temporarily covering Healthy Opportunities screening to encourage providers to gain capacity for screening Medicaid beneficiaries for unmet health-related resource needs and referring them to appropriate community-based resources prior to the launch of Medicaid managed care.&nbsp;&nbsp;</p>

Effective Jan. 1, 2021, NC Medicaid and NC Health Choice are temporarily covering Healthy Opportunities screenings to encourage providers to gain capacity for screening Medicaid beneficiaries for unmet health-related resource needs and referring them to appropriate community-based resources prior to the launch of Medicaid Managed Care.  

  • Reimbursement is limited to Carolina Access II providers and is a time limited opportunity through June 30, 2021.  
  • Coverage of this code after Medicaid Managed Care launch will be at the discretion of the health plans. 

This bulletin temporarily enables Carolina Access II providers to receive reimbursement for positive Healthy Opportunities screenings conducted using the North Carolina Department of Health and Human Services (DHHS) standard screening questions or an equivalent instrument with similar questions covering beneficiary needs related to DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety). For providers who have not already adopted a tool, we strongly encourage the use of the DHHS standard questions. 

  • Recipients of screenings are not required to be beneficiaries assigned to the Carolina Access II practice.  
  • Upon completing a positive screen, providers should refer enrollees to community-based resources to address the identified needs.  
  • While reimbursement will not be contingent upon such referrals, providers are strongly encouraged to refer beneficiaries who screen positive for unmet social needs to appropriate resources. 

Many providers in North Carolina use NCCARE360 to electronically connect those with identified needs with community resources and allow for a feedback loop on the outcome of that connection. Providers are encouraged to use NCCARE360 to support screenings and referrals for patients with unmet health-related resource needs; however, providers are not required to do so to obtain reimbursement for Healthy Opportunities screenings under this temporary policy modification.   

Providers must keep records of all screenings conducted. DHHS may audit activities conducted under this temporary policy modification at any time. 

Definitions 

  • Healthy Opportunities are unmet resource needs related to food, housing, transportation and interpersonal violence that have an impact on a person’s health, safety and well-being, as well as healthcare utilization and costs. 
  • Positive Screening means a screening that identifies the individual as having an unmet need in at least one of DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety).  

Billing Guidance for Carolina Access II Providers: HCPCS code G9919 

A. Claim Type 

Professional (CMS-1500/837P transaction) 

B. International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) 

Providers are encouraged, but not required, to include Z codes indicating a patient’s identified resource needs when submitting claims for Healthy Opportunities screenings. See table below for Z codes providers should use to indicate patients’ resource needs. 

Z Code 

Description 

Food 

Z594 

Lack of adequate food and safe drinking water 

Housing/Utilities 

Z590 

Homelessness 

Z591 

Inadequate housing 

Z598 

Other problems related to housing and economic circumstances 

Transportation 

Z599 

Problems related to housing and economic circumstances, unspecified 

Interpersonal Safety 

Z608 

Other problems related to social environment 

 

C. Code(s) 

Providers should bill the following code for new and established patients, when provided by an eligible provider in person or during a telehealth visit (audio and video). This code may not be billed during telephonic visits. Physicians, nurse practitioners, physician assistants, nurse midwives, or designated staff may bill the code. Additionally, any eligible federally qualified health centers (FQHCs), FQHC lookalikes and rural health centers (RHCs) may bill under fee-for-service reimbursement. 

Service Code 

Description (See 2020 CPT Code Book for Complete Details) 

G9919 

Screening performed and positive, and provision of recommendations. 

Coding Guidance 

  • Eligible providers bill for and receive reimbursement from positive Healthy Opportunities screens which is indicated by the accompanying z-code. 
  • Each eligible provider may bill this code up to once per 30-day period per patient receiving a positive Healthy Opportunities screening.  

D. Modifiers 

N/A- providers will not need to append modifiers to claims for Healthy Opportunities screenings. 

E. Billing Unit 

Provider(s) shall report the appropriate code(s) used which determines the billing unit(s). 

F. Place of Service 

Providers may bill code G9919 in the following places of services: 

POS Indicator 

Description 

03 

School 

04 

Homeless shelter 

05 

Indian health services free-standing facility 

06 

Indian health services provider-based facility 

07 

Tribal 638 free-standing facility 

08 

Tribal 638 prov based facility 

11 

Office 

12 

Home 

14 

Group home 

15 

Mobile unit 

16 

Temporary lodging 

20 

Urgent care facility 

21 

Inpatient hospital 

23 

Hospital emergency room 

24 

Ambulatory surgical center 

25 

Birthing center 

26 

Military treatment facility 

49 

Independent clinic 

50 

Federally qualified health center 

51 

Inpatient psychiatric facility 

52 

Psychiatric facility partial hospitalization 

53 

Community mental health center 

54 

Intermediate care facility/mentally retarded 

55 

Residential substance abuse treatment facility 

56 

Psychiatric residential treatment center 

57 

Non-res substance abuse treatment facility 

58 

Non-residential opioid treatment facility 

71 

State or local public health clinic 

72 

Rural health clinic 

99 

Other unlisted facility 

Providers may bill code G9919 as part of in-person or telehealth visits using real time audio and visual technology. This is not billable for telephonic only or portal communication care. Telehealth claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not place of service (POS) 02 (telehealth).  

G. Copayments 

H. Reimbursement 

NC Medicaid and Health Choice shall reimburse eligible providers in accordance with the published fee schedule for each positive Healthy Opportunities screening billed to code G9919.  

Additional Resources 

NC Healthy Opportunities Overview at https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities   

NC Medicaid Contact Center, 888-245-0179 

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