New Per Diem Crisis Stabilization Service Tiers and Billing Modifiers

By December 31, 2025: Billing team must update billing system to implement the new tiered crisis stabilization service structure. REQUIREMENTS: (1) Configure system to apply new billing modifiers—TF (Tier 2: Crisis-dedicated stabilization) and HA (Tier 3: Youth crisis stabilization facility)—to per diem claims using HCPCS S9485; Tier 1 (Community-based stabilization) requires no modifier. (2) Program hourly billing cap: Claims using HCPCS S9484 (hourly) are limited to 8 hours per date of service; services beyond 8 hours must convert to per diem billing with S9485. (3) Update fee schedules to reflect the increased per diem reimbursement rates (obtain current rates from ForwardHealth maximum allowable fee schedule and topic #24066). (4) Remove HMO crisis stabilization billing workflows—all crisis services must now be billed fee-for-service to county crisis programs only, even for members enrolled in MCOs. (5) Ensure billing rules validate location and intensity of services match the correct tier. (6) Train billing staff to identify service location and match to appropriate tier/modifier. (7) Update claims scrubbing logic to deny claims with incorrect modifiers or that exceed 8-hour hourly limits. Consequences: Claims submitted with incorrect tiers/modifiers, missing required modifiers on Tier 2/3 services, or exceeding 8-hour hourly caps will be denied; recoupment may occur for previously paid claims that violate the new rules; continued non-compliance may result in intermediate sanctions or program termination per Wis. Stat. § 49.45(3)(f).