Section 12. CPST Billing Requirements

The proposed regulations are very prescriptive about how CPST should be delivered. However, the billing structure does not reflect that same level of specificity. The draft identifies separate required service components, but most share the same procedure code and modifier combination, with billing differentiated only by provider type rather than the service performed.

By assigning the same billing code and modifier combination to multiple required service components, DMAS and the MCOs cannot determine from claims data which required services are actually being delivered. The only way to determine whether providers are complying with these requirements is to perform a chart audit. That seems like a missed opportunity when claims data could provide this information in real time through distinct service component modifiers.

The current billing structure also creates a claims processing issue. The draft regulations permit simultaneous billing for assessment and treatment planning when clinically appropriate, yet both services share the same billing code and modifier combination used for psychotherapy, care coordination, crisis support, and other CPST service components. Without a way to distinguish these services at the claim level, claims systems may identify legitimate simultaneous billing as duplicate or overlapping services.

Suggestion: Section 12 should be revised to include distinct billing modifiers for each CPST service component. This would allow DMAS and Medicaid MCOs to monitor utilization, spending, required service frequencies, and compliance through claims data instead of relying on what was proposed during the authorization process and waiting for a chart audit to determine what actually occurred.

Right now, claims only tell DMAS that a service was billed. They don't tell DMAS which required component of the CPST model was actually delivered, just that a claim was billed.
Distinct service component modifiers would change that. This would give DMAS and the MCOs real-time visibility into how CPST services are being delivered, identify utilization trends much sooner, and confirm that required service components are occurring. This would allow earlier intervention when service delivery does not align with the intended model.