{
  "slug": "pecos-behavioral-health-taxonomy",
  "title": "Behavioral-health PECOS taxonomy misalignment (highest-recoupment cohort)",
  "hypotheses": [
    "H38"
  ],
  "status": "published",
  "release_date": "PPEF 2026-04-01 + NPPES + CMS Medicare\u2194NUCC crosswalk (2025-10)",
  "generated_at": "2026-05-18T13:16:20+00:00",
  "methodology_version": "0.7.0-draft",
  "commit_sha": "f94199d",
  "headline": "44,875 of 147,693 comparable behavioral-health NPIs (30.38%) show a PECOS PROVIDER_TYPE that does not resolve to any NUCC code on the NPI's NPPES record via the CMS Medicare\u2194NUCC crosswalk. Behavioral-health wrong-taxonomy is the highest-recoupment-risk category under the 2026 verification rules \u2014 payer rejection is automatic, not flag-and-investigate, and recoupment covers the entire window the wrong code was in place. This subset is the priority cohort for state PI offices and behavioral-health group practices to triage. Per-state CSVs at /api/v1/states/<state>/h38-behavioral-health-pecos-mismatch.csv.",
  "numerator": 44875,
  "denominator": 147693,
  "denominator_note": "Denominator = 147,693 NPIs that are (a) Medicare-enrolled with a PROVIDER_TYPE_CD in the crosswalk, AND (b) carry at least one NUCC behavioral-health code on their NPPES record. Behavioral-health codes recognized: prefixes 101Y, 103T, 103G, 103K, 1041C, 1041S, 106E, 106H (counselor, psychologist, clinical neuropsychologist, behavior analyst, clinical/school social worker, MFT). Numerator = subset where the PECOS-resolved NUCC set has empty intersection with the NPPES set.",
  "data_source_release": "PPEF 2026-04-01 + NPPES + CMS Medicare\u2194NUCC crosswalk (2025-10)",
  "chart": {
    "type": "bar",
    "unit": "count",
    "data": [
      {
        "label": "Behavioral-health mismatch",
        "value": 44875
      },
      {
        "label": "Behavioral-health match",
        "value": 102818
      }
    ]
  },
  "per_state": [
    {
      "state": "CA",
      "matches": 5524
    },
    {
      "state": "NY",
      "matches": 2884
    },
    {
      "state": "FL",
      "matches": 2403
    },
    {
      "state": "TX",
      "matches": 2220
    },
    {
      "state": "MI",
      "matches": 2146
    },
    {
      "state": "MA",
      "matches": 2109
    },
    {
      "state": "OH",
      "matches": 2072
    },
    {
      "state": "PA",
      "matches": 1828
    },
    {
      "state": "IL",
      "matches": 1651
    },
    {
      "state": "MN",
      "matches": 1411
    },
    {
      "state": "NJ",
      "matches": 1399
    },
    {
      "state": "CO",
      "matches": 1295
    },
    {
      "state": "NC",
      "matches": 1280
    },
    {
      "state": "WA",
      "matches": 1274
    },
    {
      "state": "OR",
      "matches": 1185
    },
    {
      "state": "WI",
      "matches": 1122
    },
    {
      "state": "CT",
      "matches": 967
    },
    {
      "state": "GA",
      "matches": 888
    },
    {
      "state": "OK",
      "matches": 837
    },
    {
      "state": "IN",
      "matches": 783
    },
    {
      "state": "VA",
      "matches": 760
    },
    {
      "state": "MD",
      "matches": 735
    },
    {
      "state": "MO",
      "matches": 663
    },
    {
      "state": "KY",
      "matches": 625
    },
    {
      "state": "AZ",
      "matches": 620
    }
  ],
  "notes": "Behavioral health gets carved out from H37 because the regulatory consequences are harder. A mental-health counselor billing E/M codes their NPPES taxonomy doesn't cover, or a marriage-and-family therapist whose PECOS record was filed as a general counselor, will trigger automatic claim rejection. Then recoupment over the multi-year window the wrong code was in place. The cohort surfaced here is the highest-priority triage list for behavioral-health group practices doing pre-emptive PECOS-cleanup audits. State PI offices should treat this subset as priority within H37 for the SMD-letter Element 4 (other comprehensive measures) submission."
}