PG041 - Transitional Case Management
This is a one day PA ($1166.94) and is meant for children (0 – 21) that are transitioning out of inpatient facilities only. Since independently contracted providers cannot be reimbursed for case management, this PA group is only allowed for outpatient behavioral health agencies. This PA can be requested like any other level authorization (under admission or update CDC), and the CAR scores are not required so you can just put 99 in the CAR fields. It is important that the request date of the PA group be within seven days of the customer discharging. ODMHSAS receives a weekly download from OHCA on the children that have discharged, and will ensure that only those kids are the ones allowed to receive the PG041. This does not however mean you only have seven days to get in the information, just that the request date you ask for needs to be within a one week span of the customer leaving inpatient since this PA is covering services done while inpatient. Since the administrative rule allowing coverage of this service was effective 9/12/2014, there is unlimited back dating on this PA group going back to the date of the rule change (See OAC 317:30-5-596(1)(A)(v)(VIII).
After the PA has been issued, a provider can bill all units of transitional case management done in the last 30 days while the customer was inpatient; however, all units are billed for the day of the PA, not the dates of service. For example; Bob was inpatient 11/1/2014 to 11/30/2014, the PG041 would be requested for 12/1/2014 and the amount of units done while inpatient would all be billed for that day. The limit for regular transitional case management is 25 units PMPM, and 54 units PMPM for high intensity SOC and PACT customers. The codes can be found by going to the Rates and Codes for Agencies spreadsheet located at www.odmhsas.org/arc.htm. Regular case management will be billed with the T1017 procedure code and will have the TG modifier at the end. High intensity will also have a TG modifier at the end, but be billed under the T1016 procedure code. The rate sheet will tell you what modifier combinations are allowed depending on the level of the rendering provider.
If you have any questions, please contact the PICIS help desk at 405-521-6444 or at .