Action Required: Update Billing and Diagnostic Codes to Close FUM/FUA Gaps
Starting January 1, 2025, the criteria for follow-up after emergency department visits for mental health (FUM) will expand to include additional diagnoses, potentially requiring members to schedule follow-up appointments. Members seen in the emergency department for substance use (FUA) will also need follow-up care.
Both medical and behavioral health care providers can utilize appropriate billing and diagnostic codes to address the FUM and FUA HEDIS® gaps.
How providers can assist:
Healthcare providers serve as essential connectors between care services. They schedule follow-up appointments for patients who receive emergency department discharge for mental health or substance use issues within 7 days. The first day after hospital discharge serves as Day 1 for counting purposes. When a visit within seven days is not feasible, the patient should receive a follow-up appointment within 30 days.
The correct billing codes should be used by providers to address FUM and FUA HEDIS gaps. Both medical and mental health providers can use these codes to improve care gaps, but the codes should not guide billing practices.
FUM: Outpatient behavioral health visits for any mental health disorder diagnosis:
98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
FUM: Outpatient visit with any mental health disorder diagnosis and the correct place of service code:
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
FUA: The correct place of service code must accompany outpatient visits that diagnose substance use disorder or drug overdose or mental health provider appointments:
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
FUA: A behavioral health visit that includes any substance use disorder diagnosis or, drug overdose diagnosis, or a mental health provider visit requires FUA status:
98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
The place of service and additional codes for this measure, along with others, can be found in the PATH reference guide.
Contact the behavioral health number listed on the member ID card’s back to obtain a network behavioral health professional referral for additional assessment or treatment.
Resources
View more information and resources on UHC Provider’s Clinical Tool page or on the Optum Provider and Staff Toolkits page.
