CalAIM Behavioral Health Initiative Frequently Asked Questions
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Below is a list of frequently asked questions that were collected from technical assistance and informational webinars and submissions to the
BHCalAIM@dhcs.ca.gov email. DHCS will update this list on a quarterly basis.
Coding During Assessment
If a member receiving
services from a MHP has a co-occurring substance use disorder (SUD), and the
mental health provider's session only focuses on the SUD need, is this
acceptable? What about a DMC or DMC-ODS provider serving a member with a mental health disorder?
Reference BHIN 22-013
Clinically appropriate and covered Specialty Mental Health Services (SMHS) delivered by MHP providers are covered Medi-Cal services whether or not the member has a co-occurring SUD. The reason for the service encounter (ICD-10-CM code) must correspond to the medically necessary service provided to the member. If the service is a SMHS, then the reason for the service encounter must include a ICD-10-CM code that corresponds to their mental health (see BHIN 22-013). The session must primarily address the member’s mental health, e.g. symptom, condition, diagnosis, and/or risk factors, which can include co-occurring SUD.
Similarly, clinically appropriate and covered DMC services delivered by DMC providers and DMC-ODS services delivered by DMC-ODS providers are covered by DMC counties and DMC-ODS counties, respectively, whether or not the member has a co-occurring mental health condition. If the service is a SUD service (DMC/DMC-ODS), then the reason for the service encounter must include a ICD-10-CM code that corresponds to their SUD (see BHIN 22-013). The session must primarily address the member’s substance use, e.g. symptom, condition, diagnosis, and/or risk factors, which can include co-occurring mental health conditions.
For further guidance on the use of ICD-10-CM diagnosis codes / reason for the service encounter, please refer to the CMS code tabular (list of included ICD-10-CM codes for SMHS and DMC/DMC-ODS services) and the CMS coding guidelines for 2024. These guidelines are updated at least annually.
What ICD-10 codes should a provider use to claim for services provided to a beneficiary that has not yet received a diagnosis?
Reference BHIN 22-013
MHPs, DMC and DMC-ODS programs and providers are required to use appropriate ICD-10 diagnosis codes to submit claims to receive reimbursement of Federal Financial Participation. BHIN 22-013 identifies ICD-10 codes that may be used during the assessment phase of a member's treatment when a diagnosis has yet to be established. 