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7.3 The 12-Hour System Limitation
The following provider types are limited in the Medicaid claims processing system to reimburse for a maximum combined total of 12 hour per day per provider system limitation for inpatient and outpatient behavioral health services:
• Clinical Nurse Specialist (CNS)
•LCSW
•LMFT
•LPC
•Nurse Practitioner (NP)
•Physician assistant (PA)
•Psychologist
Because MDs and doctors of osteopathy DOs can delegate and may submit claims in excess of 12 hour per day, they are not subject to the 12-hour system limitation.
Providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day due to the manner in which group therapy is billed.
Because a psychologist can delegate to multiple LPAs and may submit claims for LPA services in excess of 12 hours per day, LPAs are not subject to the 12-hour system limitation.
All providers, including MDs and DOs and each provider to whom they delegate, are subject to retrospective review as outlined below, including the following:
•MDs and DOs and each provider to whom they delegate
•LPAs performing services under the direct supervision of a psychologist.
Court-ordered services are not subject to the 12-hour system limitation per provider per day when billed with modifier H9.
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