Primary Care Coding Alert

Answer: Simply having a master’s degree does not automatically qualify someone as an eligible Medicare provider for purposes of rendering behavioral health therapy. Medicare does not consider master’s degree-level providers as qualified healthcare professionals (QHP’s) — unless they are also licensed clinical social workers (LCSW) as defined by your state licensing bureau. Therefore, reporting HCPCS modifier HO (Masters degree level) won’t automatically satisfy the requirements for the BHI claim. Different states have different licensure and other requirements, which may differ from Medicare requirements in some cases.

Start by verifying whether the provider in question is eligible under Medicare rules to bill for the therapy service. If they are, then check the reason for the denial on the remittance advice and go from there to determine whether an appeal or some other response is in order