This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
This bulletin clarifies and emphasizes key requirements governing concurrent billing under the Clinical Coverage Policy (CCP) 8F, Research-Based Behavioral Health Treatment (RH-BHT). Concurrent billing is permitted only in the exceptions listed in CCP 8F Attachment A, Section C; all other concurrent billing is prohibited until further notice.
Terminology used in this bulletin
- A Licensed, Qualified Health Care Professional (LQASP) means a licensed, qualified health professional who meets the licensed provider criteria in CCP 8F, Section 6.1 Provider Roles (e.g., licensed psychologist, physician) and corresponds to the Qualified Health Professional (QHP) referenced in Current Procedural Terminology (CPT) guidance for codes such as 97155.
- “Paraprofessional” has the meaning listed in CCP 8F, Section 6.1(c), i.e., a technician delivering treatment by protocol under supervision.
For purposes of this guidance, concurrent billing occurs when two or more providers bill separate CPT codes for beneficiary-facing services provided to the same beneficiary during the same time period.
For example, concurrent billing may occur when a LQASP bills CPT code 97155 while a paraprofessional bills CPT code 97153, with both providers delivering services directly to the same beneficiary during the same time period.
Exceptions as per CCP 8F Attachment A, Section C
- CPT code 97153: May be billed with CPT code 97155 when a paraprofessional is providing 97153 while being observed by an eligible provider, consistent with the requirements outlined in CCP 8F Attachment B: Applied Behavior Analysis Service Definition, Provider Requirements and Roles.
- CPT code 97154: May be billed with CPT code 97155 when a paraprofessional is providing 97154 while being observed by an eligible provider, consistent with the requirements outlined in CCP 8F Attachment B: Applied Behavior Analysis Service Definition, Provider Requirements and Roles.
- CPT code 97155: May be billed with CPT code 97153 or 97154 when the applicable requirements are met. A single rendering provider may not bill 97153 or 97154 and 97155 for the same time period.
There are services under CCP 8F which may not be beneficiary-facing (e.g., caregiver training billable under CPT 97156 without the beneficiary present; reassessment data analysis and treatment planning billable under CPT 97151 without the beneficiary present). Such non-beneficiary-facing services are not considered concurrent if billed at the same time as billable, beneficiary-facing services provided by another clinician under this policy.
Examples that would not be considered concurrent billing and are allowed under CCP 8F
- A LQASP may provide beneficiary caregiver training (e.g., CPT code 97156) to the caregiver without the beneficiary present while, during the same time period, a paraprofessional provides direct treatment services (e.g., CPT code 97153) to the beneficiary.
- This scenario does not constitute concurrent billing because the two providers are delivering separate services to different individuals at the same time—one provider is working with the beneficiary’s caregiver, while the other is providing direct treatment to the beneficiary.
- A LQASP may perform billable, non-beneficiary-facing activities related to a reassessment of a beneficiary (e.g., CPT code 97151) while, during the same time period, a paraprofessional provides direct treatment services (e.g., CPT code 97153) to the beneficiary.
- This scenario does not constitute concurrent billing because the LQASP is performing non-beneficiary-facing reassessment analysis and treatment planning, while the paraprofessional is providing direct treatment to the beneficiary.
Policy status and remedial measures
The policy regarding concurrent billing remains subject to future revision, as needed, to support program integrity, prevent duplicate payments, and ensure accurate attribution of service minutes. When providing services under CCP 8F, providers must ensure that all service note documentation is completed in accordance with the requirements outlined in CCP 8F, Section 5.5.1, Contents of a Service Note.
CPT Code 97151:
Service note documentation must clearly differentiate the duration and time (in/out) of LQASP activities that are beneficiary-facing versus non-beneficiary-facing.
CPT Code 97156:
- Service note documentation must clearly differentiate the duration and time (in/out) when the LQASP is working directly with the caregiver(s) and beneficiary together versus working only with the caregiver(s).
- When the LQASP provides caregiver training with the beneficiary present and the caregiver(s) participating, other direct services (e.g., CPT codes 97153 or 97154) cannot be billed concurrently for the same time period.
Contact
For information on NC Medicaid Managed Care health plan billing and requirements, please contact health plans leveraging the information on the Health Plan Contacts and Resources page.