Billing for case management services?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

psyduck1990

Full Member
2+ Year Member
Joined
Feb 29, 2020
Messages
18
Reaction score
31
Does anyone have experience with hiring a case manager for an outpatient clinic and billing insurance for their services? I was wondering what codes are used and am struggling to find useful information online.

Members don't see this ad.
 
Interesting idea. But I suspect you might not find positives answers to support this. My understanding is its done in CMHC because medicaid has these codes, and specifically has things setup to to acknowledge and bill for it. I don't recall this being a commercial insurance favored approach.

One angle to possibly search is the nursing side. I know RNs (and maybe even LPNs?) can bill certain nurse specific codes, but they have an "incident to" element where there needs to be a doc in the clinic, and the service they are doing needs to tie back to a specific comment/order/plan in the doctors note. One Big Box shop job I had in the past had an RN in clinic who did refills, LAI injections, or other 'case management' type things like this for the SMI population managed in the clinic. But it was a relic from the days when they had the CMHC type medicaid contract. They kept some patients after their contract ended, which was probably not wise, and I believe those codes were more damage control for the clinic in revenue then they were profit generating.

Curious to know what you find.

What type of clinic setup do you have and what tasks are you looking to plug?
 
These are bundled services so you can’t bill for them. They are usually paid for by block grants or facility fees. Case managers are service providers not billing providers meaning they aren’t expected to generate revenue to justify their position. Insurance based clinics that aren't facility based don't offer these services. Other than that, they can be fee for service (i.e. cash based). There are codes for complex/chronic disease management, and collaborative care management, but not general case management services. Some people use therapy codes but that wouldn't be appropriate for more general case management services, and they would have to be licensed therapists.
 
Top