Behavioral Health Crisis Evaluation Billing FAQs

This page answers the most frequently asked questions (FAQs) about how to bill for behavioral health (BH) services in acute and psychiatric hospitals.

General Billing Guidance

1. Can observational services be billed for on the same day as a BH crisis evaluation?
   • If the patient is receiving a medical observation, the hospital may bill both observation codes and BH crisis evaluation (S9485) on the same day. However, the observation cannot be billed as a replacement for BH crisis management (S9485 with V1 or V2). 
2. Can hospitals bill for BH crisis evaluation, observation, and BH crisis management services if the patient meets the criteria for all three?
   • A hospital may only bill for one of the following services on any one calendar day for a MassHealth member - BH crisis evaluation, BH crisis management, or BH observation.
   • If the patient is receiving a medical observation, the hospital may bill both observation codes and BH crisis management (S9485 with V1 or V2) on the same day. However, the observation cannot be billed as a replacement for BH crisis management (S9485 with V1 or V2).
   • The BH crisis evaluation service should be provided during the first calendar day of an individual’s readiness to receive such an evaluation and should be billed no more than once per hospital stay.
3. When does the BH crisis evaluation service start? 
   • BH crisis evaluation (S9485 without a modifier) may be billed for the first calendar day of a member’s readiness to receive such an evaluation.
4. What is the timeframe for completing BH crisis evaluations?
   • BH crisis evaluations should be completed within 60 minutes of a patient’s readiness to receive the evaluation as stated in Appendix I of the RY24 Acute Hospital RFA, Section II.C.
5. Can the hospital bill the S9485 code when a MassHealth patient receives a BH crisis evaluation service on the hospital’s med/surg floor (either as a boarder or as an admitted inpatient)?
   • Yes
6. May consulting psychiatrists and psychiatric nurse practitioners (NPs) bill code 90792 on the same day a patient receives a BH crisis evaluation in the Emergency Department (ED)? 
   • Review the requirements and clinical expectations listed in Appendix I of the RY24 Acute Hospital RFA. If clinical judgement indicates additional psychiatric consultation is appropriate, indicated, and differentiated by the code definitions, then billing is correct. MassHealth expects treatment teams to use their best clinical judgement when billing professional service codes in addition to the BH crisis evaluation.
7. If the BH crisis evaluation is considered a per diem service, can a hospital bill for re-evaluations? Can you define what per diem means for BH crisis evaluations?
   • As noted in Section 5.C.11 and Appendix I of the Acute Hospital RFA, BH crisis evaluations performed in the ED should be billed by using the per diem procedure code, S9485. This procedure code may only be billed for BH crisis evaluations provided by a qualified behavioral health professional to an individual presenting in a behavioral health crisis. Qualified behavioral health professionals can include, but not be limited to, a:
     1. licensed physician who specializes in the practice of psychiatry;
     2. licensed psychologist;
     3. licensed independent clinical social worker;
     4. licensed certified social worker;
     5. licensed mental health counselor;
     6. licensed physician assistant who practices in the field of psychiatry;
     7. advanced practice registered nurses who practice in the field of psychiatry, including but not limited to licensed nurse practitioners and licensed psychiatric clinical nurse specialists;
     8. or healthcare provider qualified within the scope of the individual’s license to conduct a BH crisis evaluation of a mental health condition, including an intern, resident or fellow under the policies and practices of the hospital and medical staff.
   • The BH crisis evaluation includes the initial assessment of risk, diagnosis, and treatment needs, the initial clinical stabilization interventions, and the determination and coordination of appropriate dispositions. Therefore, this code may be billed once per member per crisis episode.
   • Once a patient is released, any returns would count as a new encounter, and therefore the hospital could bill, using code S9485, for another BH crisis evaluation service.

Technical Billing Guidance

1. What revenue code should hospitals use with HCPCS code S9485 for MassHealth fee-for-service (FFS) members?
   • Use standard billing rules. Note: for professional billing (837P), no revenue code is required. For institutional claims (837I), a revenue code is required.
2. When providers submit facility claims for S9485, must they use Revenue Code 9xx?
   • Yes. 
3. Will MassHealth reimburse for professional fees, including for BH crisis evaluation and management services, in addition to BH crisis evaluation?
   • Yes. The S9485 code encompasses all activities included in the initial BH crisis evaluation. Hospitals are allowed to bill for other behavioral health interventions provided to the same member on the same day, as is the current practice.
   • Clinical services outside the scope of the BH crisis evaluation service include, but are not limited to, direct psychiatric evaluation of the member by a psychiatrist or advanced practice provider (advanced practice registered nurses or physician assistants) requested by the primary hospital medical team for diagnostic clarification and treatment recommendations.
   • See the RY24 Acute Hospital RFA, Appendix I, Section II.C for procedural components of BH crisis evaluation Services. Procedural components are considered in scope of the respective services.
4. Is a modifier required to bill for BH crisis evaluation services?
   • No modifiers are required when billing S9485 for BH crisis evaluations. View plan-specific billing guidance for additional details.

Allowable Providers

1. Can a consulting psychiatrist/psychiatric NP continue to bill professionally on the same day the hospital bills MassHealth for the initial BH crisis evaluation service?
   • Yes. The S9485 code encompasses all activities included in the initial BH crisis evaluation and does not prevent other behavioral health interventions for the same member on the same day to be billed and reimbursed separately, as is the current practice.
2. Are behavioral health professionals allowed to provide BH crisis evaluations, including masters trained but not yet licensed professionals, if they are working under the supervision of a licensed professional?
   • Behavioral health professionals allowed to provide evaluations include appropriately qualified and supervised professionals conducting BH crisis evaluations as part of the hospital’s multidisciplinary staff.
3. Must S9485 be billed by individual service providers? 
   • No. S9485 must be billed through the hospital provider.

Telehealth

1. May providers bill the S9485 code using a telehealth modifier if the BH crisis evaluation is performed by clinicians who are not on-site and utilizing correct telehealth modalities? 
   • Yes, the S9485 code may be billed using the telehealth modifier. See MassHealth All Provider Bulletin 379 for more information. 
2. May providers bill the S9485 code for BH crisis evaluation services using modifiers other than the telehealth modifier?
   • No.

Insurer-Specific Guidance

1. How should hospitals bill for the BH crisis evaluation when a commercial payer is primary and MassHealth is secondary?
   • For commercial members, contact the commercial plan for billing guidance.
2. Will the BH crisis evaluation services be paid under Medical Benefit through MassHealth or MCO directly?
   • All BH crisis evaluation services provided on or after January 3, 2023, should be billed directly to MCEs or MassHealth FFS, depending on member enrollment. Follow plan-specific billing guidance for additional information.
3. What are the technical billing requirements for hospitals to bill for ED-based BH crisis evaluations for each MassHealth-contract managed care plan and MassHealth FFS?
   • Refer to the specific billing guidance from each MassHealth contracted MCE and for MassHealth FFS that accompanies this FAQ.  Additionally, the ED-based BH crisis evaluations are only for the first calendar day of an individual’s readiness to receive such an evaluation and is distinct from patients who are awaiting placement for more than 24 hours.
4. Are dual Medicare-Medicaid members eligible for BH Crisis Evaluation services?
   • Yes, dual eligible plan members are eligible for BH crisis evaluation services. 
5. When a MassHealth member has Medicare primary and MassHealth secondary, should providers bill the S9485 code to Medicare first?
   • When a member has Medicare primary and MassHealth secondary, the provider should bill S9485 to MassHealth and receive the MassHealth allowed amount as reimbursement for claims submitted.
6. Are Medicare Advantage members who have MassHealth secondary coverage eligible for BH crisis evaluation services?
   • Hospitals may follow the same billing instructions for MassHealth members with Third Party Liability whether they have traditional Medicare or Medicare Advantage as the primary insurer. If the patient only has Medicare (traditional or Medicare Advantage), without MassHealth secondary, the hospital may bill Massachusetts Behavioral Health Partnership (MBHP) for BH crisis evaluation services.
7. May providers submit claims for S9485 for individuals receiving Health Safety Net (HSN) services? 
   • Yes. Providers may bill S9485 for individuals receiving HSN services by submitting claims to MBHP.
8. How should hospitals bill for behavioral health crisis evaluation services provided to the non-MassHealth patient populations (including those without insurance and those with Medicare only)?
   • Hospitals should bill MBHP for initial behavioral health crisis evaluation services provided to uninsured individuals and persons covered by Medicare.
9. How does the MassHealth ED BH crisis evaluation requirement interact with the Commercial ED Boarding Mandate when the commercial payor is primary and MassHealth is secondary?  
   • The ED BH crisis evaluation service code may only be billed for MassHealth members presenting to the ED in a behavioral health crisis and does not apply to care coordination, treatment, and supports provided to individuals awaiting placement at a 24-hour level of behavioral health care. Contact the specific commercial plans for their ED Boarding Mandate billing guidance.
10. How should hospitals bill for BH crisis evaluation services when the patient has Medicare primary, commercial secondary, and MassHealth tertiary?
    • The provider should first bill the secondary commercial health plan for BH crisis evaluation services and then bill S9485 to MassHealth and receive the MassHealth allowed amount as reimbursement for claims submitted.

Date published:	April 30, 2024