2026 July Network Connection

REQUIREMENTS: 1. By July 1, 2026 (immediate): Billing team must update claim submission protocols to enforce stricter documentation requirements for CPT 90785. Create audit checklist requiring: - Specific communication challenges documented in medical record - Description of challenges affecting clinical interaction - Documentation of interactive methods used - Statements explaining why standard communication approaches were insufficient 2. Immediately: Communicate to all psychiatric/behavioral health providers the four QUALIFYING uses of CPT 90785: - Involvement of individuals legally responsible for member's care - Participation of family members, caregivers, or interpreters at member's request - Coordination with external entities (schools, social services, legal authorities) - Communication barriers requiring specialized methods 3. Immediately: Distribute list of NON-QUALIFYING uses to providers. Staff must flag and reject claims for: - Translation/interpretation services alone - Child work or play therapy without specific complicating factor - Routine parent involvement or parent attendance at sessions - Routine/expected services (increased time alone does NOT qualify) 4. Before July 15, 2026: Billing team must audit outstanding CPT 90785 claims submitted in past 60 days against new documentation standards. Resubmit claims with compliant documentation or contact providers for missing information. 5. For nail pathogen panels: Billing team must implement system edits to flag podiatry and specialist claims for nail pathogen testing (molecular pathology codes) when billed as first-line testing. Require provider documentation of: - Why traditional methods were insufficient - Medical necessity for complex/treatment-resistant cases - Justification for multiple units if applicable 6. Effective immediately: Review Presbyterian Practitioner and Provider Manuals Chapter 16 (fraud, waste, abuse examples) as reference material. Escalate questionable CPT 90785 or nail pathogen panel claims to Compliance and Fraud, Waste, and Abuse Hotline (1-888-435-4361 or PHPFraud@phs.org) before payment. CONSEQUENCES: Claims submitted without adequate documentation may be subject to audit or review, and payment may be adjusted or denied if billing requirements are not met.