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HIPAA: EPSDT Psychology, Mental and Behavioral Health Services Code Conversion

HIPAA-mandated changes to billing requirements for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health services are effective August 1, 2019.

HIPAA is the acronym for the Health Insurance Portability and Accountability Act which was passed by Congress in 1996. In addition to eliminating the use of HCPCS Level III local codes, HIPAA does the following:

  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs.
  • Reduces health care fraud and abuse.
  • Mandates industry-wide standards for health care information on electronic billing and other processes.
  • Requires the protection and confidential handling of protected health information.

Historically, California has historically used thousands of HCPCS Level III or local codes (also known as interim codes) for billing and reimbursement of services and supplies. National codes, such as CPT codes are typically more specific in nature compared to local codes. Using HIPAA-compliant CPT codes:

  • Simplifies the processes and decrease the costs associated with payment for health care services.
  • Improves the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (for example, medical practices, hospitals and health care plans).
  • Provides standardization and consistency in medical service coding.
  • Characterizes a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.

The use of a HIPAA-compliant CPT codes is required to bill for the service visit with the recipient on or after August 1, 2019.

The claim may consist of one of the following:

  • CPT code with modifier(s);
  • Revenue code and CPT code with modifier(s).

For dates of service on or after August 1, 2019, claims submitted with HCPCS Level III local codes are no longer reimbursable.

The following Frequently Asked Questions (FAQs) provide an overview of some of the changes occurring during this conversion.
  1. What does the conversion from HCPCS Level III local codes to CPT codes mean for billing EPSDT psychology, mental and behavioral health services?

    Effective for dates of service on or after August 1, 2019, EPSDT psychology, mental and behavioral health services that are currently billed using HCPCS Level III local codes, require specified CPT national codes.

  2. What codes are changing in this code conversion?

    The following HCPCS Level III local Z-codes are converting to CPT codes: Z5814, Z5816 and Z5820. Codes Z5800, Z5810 and Z5850 are no longer reimbursable.

    More information regarding local codes and national codes is available on the New EPSDT Psychology, Mental & Behavioral Health Code Conversion Billing Guide.

  3. Do I have to bill the codes recommended on the crosswalk?

    No. The intent of the Crosswalk is to be a general guide only to assist in the seamless transition from HCPCS Level III local codes to HIPAA-compliant national codes. Please adapt to your billing situation.

  4. How do I know if I am affected by the conversion to the HIPAA compliant billing codes?

    Providers that currently submit claims using local/interim codes for their EPSDT psychology, mental and behavioral health services need to bill with HIPAA-compliant national codes for dates of service on or after August 1, 2019.

  5. What claim forms do I use to bill the national codes?

    The national codes in this code conversion may be billed on a CMS-1500 or UB-04 outpatient claim form or through ANSI 837I/837P transactions.

  6. What billing changes should I expect to see with the HIPAA compliant national billing codes?

    Instead of billing with local codes, providers may submit claims using:

    • CPT code(s) with a modifier, or

    • Revenue code and CPT code(s) with a modifier.

    Please refer to the New EPSDT Psychology, Mental & Behavioral Health Code Conversion Billing Guide for the appropriate codes to use for these services.

  7. How dose the conversion affect claims billed with dates of service prior to August 1, 2019?

    Providers are encouraged to continue to bill with HCPCS Level III local codes for dates of service on or before July 31, 2019. Begin billing with HIPAA-compliant CPT codes for dates of service on or after August 1, 2019.

  8. What is EPSDT?

    Early and Periodic Screening, Diagnostic and Treatment is a Medi-Cal benefit for individuals younger than 21 years of age who have full-scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Treatment services are provided based upon the identified health care need and diagnosis. EPSDT services include all services covered by Medi-Cal. In addition to regular Medi-Cal benefits, recipients younger than 21 years of age may receive additional medically necessary services.

  9. What is a modifier code?

    Modifier codes are two-character codes used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service rendered by a provider. Modifiers help further describe a procedure code without changing its definition. Omitting or billing with incorrect modifiers can result in inaccuracies with provider reimbursement and health service records.

  10. What specific modifier(s) do I need to use to bill with the codes for EPSDT psychology, mental and behavioral health claims?

    Modifier code EP (service provided as part of Medicaid Early and Periodic, Screening, Diagnostic and Treatment) allows for the distinction between psychology, mental and behavioral health services rendered to children and psychology, mental and behavioral health services rendered to adults. It is applicable for EPSDT psychology, mental and behavioral health services claims for dates of service on or after August 1, 2019.

  11. What is a revenue code?

    A revenue code identifies specific accommodations, ancillary service, or unique billing calculations or arrangements. Revenue codes are four digits and accompany CPT and HCPCS Level II national procedure code(s) billed on a claim.

  12. What revenue code do I use to bill with the codes for EPSDT psychology, mental and behavioral health claims?

    Applicable revenue codes in this conversion are 0914 and 0900 for UB-04 claim forms or ANSI 837I transactions. Begin using these revenue codes for dates of service on or after August 1, 2019.

    Revenue codes are not required on CMS-1500 claim forms or ANSI 837P transactions.

  13. Are SARs/eSARs required for CCS/GHPP recipients when submitting EPSDT claims?

    Service Authorization Requests (SARs) and electronic SARs (eSARs) are required for California Children’s Services (CCS)/Genetically Handicapped Persons Program (GHPP) eligible recipients under 21 years of age. If a recipient under 21 years of age is not eligible for CCS/GHPP, a Treatment Authorization Request (TAR) is used for EPSDT services.

  14. How does this conversion affect my SARs/eSARs?

    Effective for dates of service on or after August 1, 2019, new SARs/eSARs for EPSDT psychology, mental and behavioral health services must include CPT national code(s). SARs/eSARs using the HCPCS Level III local codes are only valid for dates of service on or before July 31, 2019.

    For more information on SAR and eSAR submissions, please refer to the California Children’s Services (CCS) Program Service Authorization Request (SAR) section of the Part 2 provider manual.

  15. How does this conversion affect my TARs and eTARs?

    Effective for dates of service on or after August 1, 2019, new TARs/eTARs for EPSDT psychology, mental and behavioral health services must include CPT national codes. TARs/eTARs using the HCPCS Level III local codes are only valid for dates of service on or before July 31, 2019.

    For more information on TAR and eTAR submissions please refer to the TAR Completion section of the Part 2 provider manual.

  16. Do I need to update my billing software?

    Updates may be needed. Providers are recommended to inquire with their vendors and billing/system contractors to determine if any software changes are needed and make the necessary changes when applicable.

  17. How do I test/validate that my system changes are compatible with the code conversion?

    Submitters may test status to ensure accurate file format, completeness and validity for HIPAA‑compliant claims transactions by logging into the Medi-Cal test site using their submitter ID and password. Instructions for Computer Media Claims (CMC) testing may be found in the Testing and Activation Procedures section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual.

  18. Whom can I contact if I have additional questions or concerns?

    Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers call (916) 636-1200. Providers calling from outside of California call the Out-of-State Provider Unit at (916) 636-1960 from 8 a.m. to 5 p.m. Monday through Friday, except holidays.

    For electronic claim submission questions, contact the TSC at 1-800-541-5555, select option 4 for the Technical Helpdesk and option 2 for CMC.

    All other questions for the EPSDT psychology, mental and behavioral health services code conversion may be submitted via email to CAMMISCodeConversion@dxc.com.