016.06.16 Ark. Code R. 024
Listed below are tiie covered services for the ARKids First-B program. Tliis chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.
Program Services | Benefit Coverage and Restrictions | Prior Authorization/ PCP Referral* | Co-payment/ Coinsurance/ Cost Sharing Requirement** |
Ambulance (Emergency Only) | Medical Necessity | None | $10 per trip |
Ambulatory Surgical Center | Medical Necessity | PCP Referral | $10 per visit |
Audioiogical Services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD ranqe (View ICD codes.)) | Medical Necessity | None | None |
Certified Nurse-Midwife | Medical Necessity | PCP Referral | $10 per visit |
Chiropractor | Medical Necessity | PCP Referral | $10 per visit |
Dental Care | Routine dental care and orthodontia services | None - PA for inter-periodic screens and orthodontia services | $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in Section 262.120 | PCP Referral and Prescription | 10% of Medicaid allowed amount per DME item cost-share |
Emergency Dept. Services | |||
Emergency | Medical Necessity | None | $10 per visit |
Non-Emergency | Medical Necessity | PCP Referral | $10 per visit |
Assessment | Medical Necessity | None | $10 per visit |
Family Planning | Medical Necessity | None | None |
Federally Qualified Health Center (FQHC) | Medical Necessity | PCP Referral | $10 per visit |
Home Health | Medical Necessity (10 visits per state fiscal year (July 1 through June 30) | PCP Referral | $10 per visit |
Hospital, Inpatient | Medical Necessity | PA on stays over 4 days if age 1 or over | 10% of first inpatient day |
Hospital, Outpatient | Medical Necessity | PCP refen-al | $10 per visit |
Inpatient Psychiatric Hospital and Psychiatric Residential Treatment Facility | Medical Necessity | PA & Certification of Need is required prior to admittance | 10% of first inpatient day |
Immunizations | All per protocol | None | None |
Laboratory & X-Ray | Medical Necessity | PCP Refen-al | $10 per visit |
Medical Supplies | Medical Necessity Benefit of $125/mo. Covered supplies listed in Section 262.110 | PCP Prescriptions PA required on supply amounts exceeding $125/mo | None |
Mental and Behavioral Health, Outpatient School-Based Mental Health | Medical Necessity Medical Necessity | PCP Refen-al PA on treatment services PA Required (See Section 250.000 of the School-Based Mental Health provider manual.) | $10 per visit $10 per visit |
Nurse Practitioner | Medical Necessity | PCP Refen-al | $10 per visit |
Physician | Medical Necessity | PCP refen-al to specialist and inpatient professional services | $10 per visit |
Podiatry | Medical Necessity | PCP Referral | $10 per visit |
Prenatal Care | Medical Necessity | None | None |
Prescription Drugs | Medical Necessity | Prescription | Up to $5 per prescription (Must use generic, if available)*** |
Preventive Health Screenings | All per protocol | PCP Administration or PCP Referral | None |
Rural Health Clinic | Medical Necessity | PCP Refen-al | $10 per visit |
Speech Therapy | Medical Necessity | PCP Referral | $10 per visit |
4 evaluation units (1 unit | Authorization | ||
=30 min) per state fiscal | required on | ||
year | extended benefit of | ||
4 therapy units (1 unit=15 min) daily | services | ||
Occupational | Medical Necessity | PCP Referral | $10 per visit |
Therapy | 4 evaluation units (1 unit = 30 min) per state fiscal year | Authorization required on extended benefit of | |
4 therapy units (1 unit =15 min) daily | services | ||
Physical Therapy | Medical Necessity | PCP Referral | $10 per visit |
4 evaluation units (1 unit = 30 min) per state fiscal year | Authorization required on extended benefit of | ||
4 therapy units (1 unit =15 min) daily | services | ||
Substance Abuse Treatment Services (SATS) | Medical Necessity | Psychiatrist or Physician Prescription (See Section 221.000 of SATS manual) | $10 per visit |
Prior Authorization required for all substance abuse treatment services, except codes H0001 &T1007 when billed with no modifier. Codes H0001 & T1007 require prior authorization when billed with a modifier (See Section 231.100 of SATS manual). Prior Authorization required on extended benefit of services (See Section 230.000 of SATS manual) | |||
Vision Care | |||
Eye Exam | One (1) routine eye exam (refraction) every 12 months | None | $10 per visit |
Eyeglasses | One (1) pair every 12 months | None | None |
"Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.
"ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.
""ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.
Services Not Covered for ARKids First-B Beneficiaries:
Audiological Services; EXCEPTION, Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range. (View ICD codes.)
Child Health Management Services (CHMS)
Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Developmental Day Treatment Clinic Services (DDTCS)
Diapers, Underpads and Incontinence Supplies
Domiciliary Care
End Stage Renal Disease Services
Hearing Aids
Hospice
Hyperalimentation
Non-Emergency Transportation
Nursing Facilities
Orthotic Appliances and Prosthetic Devices
Personal Care
Private Duty Nursing Services
Rehabilitation Therapy for Chemical Dependency
Rehabilitative Services for Children
Rehabilitative Services for Persons with Physical Disabilities (RSPD)
Targeted Case Management Ventilator Services
Medicaid (Arkansas l\/ledical Assistance Program) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section 1 of this manual. Reimbursement will be made for allowed services rendered by a Medicaid enrolled provider within the Medicaid Program limitations as outlined in Section 11 of this manual.
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
To enroll as a freestanding residential treatment center or as a residential treatment unit within an inpatient psychiatric hospital, the inpatient psychiatric provider must meet both of the conditions listed below:
The Facility-Based Community Reintegration Program is designed to serve as an intermediate level of care between inpatient psychiatric facilities and outpatient services. To enroll as a freestanding Facility-Based Community Reintegration Program unit or as a Facility-Based Community Reintegration Program unit within an inpatient psychiatric hospital, the inpatient psychiatric provider must meet all of the conditions listed below:
This manual, the Inpatient Psychiatric Services for Under Age 21 Provider Manual, shall govern all aspects of services provided as well as claim submissions for beneficiaries of the Facility-Based Community Reintegration Program.
Inpatient psychiatric services covered by the Arkansas Medicaid Program must be provided:
A standardized independent assessment will determine eligibility for Inpatient Psychiatric Services for Persons Under Age 21. The standardized independent assessment must be perfonned by an independent entity.
The independent assessment will contain additional criteria and questions, which will be asked based upon results from the independent assessment to detennine eligibility for Inpatient Psychiatric Sen/ices for Persons Under Age 21. Acute inpatient psychiatric care will not require an independent assessment.
The standardized independent assessment must be conducted at least every 12 months by an independent assessor in consultation with the beneficiary and anyone the beneficiary requests to participate in the standardized independent assessment. The standardized independent assessment will also take into consideration information obtained from behavioral health service providers that are providing services to the beneficiary.
A beneficiary must be referred to the independent assessment entity to evaluate whether the beneficiary meets the eligibility criteria for Inpatient Psychiatric Services for Persons Under Age 21. The following are allowable methods of referral to receive a standardized independent assessment for determination of eligibility for Inpatient Psychiatric Services for Persons Under Age 21;
A re-assessment can be requested by the direct behavioral health service provider or the care coordination entity if the direct behavioral health service provider or care coordination entity determines the beneficiary's needs are not being met or the beneficiary is not benefitting from the Inpatient Psychiatric Services for Persons Under Age 21 being provided.
The independent assessor vi/ill contact the beneficiary to be assessed within 48 hours of referral and will complete the fece-to-face assessment within 14 calendar days. For identified priority populations, the independent assessor will contact the beneficiary to be assessed within 24 hours of notification from the beneficiary's provider and will complete the assessment within 7 days of the notification. Examples of priority population include, but are not to be limited to:
Inpatient psychiatric services are covered by Ari[LESS THAN]ansas Medicaid only when provided in:
Each psychiatric residential treatment facility and Facility-Based Community Reintegration Program that provides inpatient psychiatric services to individuals under age 21 must attest, in writing, that the facility is in compliance with the Centers for Medicare and Medicaid Service (CMS) standards governing the use of restraint and seclusion. This attestation must be signed by the facility director.
A facility with a current provider agreement with the Medicaid agency must provide a letter of attestation no later than July 21st of each year. Attestations must be sent to each state Medicaid agency (SMA) where the PRTF has established a provider agreement.
Exceptions:
Attestation letters must be sent to the Medicaid Provider Enrollment Unit. View or print the contact information for the Medicaid Provider Enrollment Unit.
A facility enrolling as a Medicaid provider must meet this requirement at the time it executes a provider agreement with the Medicaid agency.
A federal provider identification number is assigned to each provider who meets the attestation requirement. The identification numbers for PRTFs and Facility-Based Community Reintegration Programs will have five digits and one letter. The first two digits identify the state in which the facility is located. This number is then followed by the letter L and then by three digits and is numbered according to the order in which a facility was identified.
Serious Injuries and Attempted Suicides
The interim process for reporting deaths will follow a similar process as currently in place for the death reporting process for hospitals. The roles and responsibilities of the appropriate entities are outlined below.
The CMS CO is responsible for maintaining a central log of the death infomiation reported from the CMS RO.
Education and Training
The facility must require staff to have ongoing education, training and demonstrated knowledge of:
The per diem rates for Facility-Based Community Reintegration Programs are established at the lesser of:
The budgeted per diem cost is calculated from the annual budget, which ail Facility-Based Community Reintegration Program providers are required to submit for the upcoming state fiscal year (July 1st through June 30th). Annual budgets are due by April 30th. Should April 30th fall on a Saturday, Sunday or state or federal holiday, the due date shall be the following business day. Failure to submit the budget by April 30th may result in the suspension of reimbursement until the budget is submitted. Rates are calculated annually and are effective for dates of service occurring during the state fiscal year for which the budgets have been prepared.
New providers are required to submit a full year's annual budget for the current state fiscal year (July 1st through June 30th) at the time of enrollment. This budget is used to set their rate at the lesser of the budgeted allowable cost per day or the upper limit (cap) of $245 per day.
inpatient psychiatric hospitals, residential treatment units, Facility-Based Community Reintegration Programs and Sexual Offender Programs must submit an annual or partial period hospital cost report to the Arkansas Medicaid Program. Providers with less than a full 12-month reporting period are also required to submit a hospital cost report for the shorter period. Cost reports are due no later than five months following the close of the provider's fiscal year end. Extensions will not be allowed. Failure to file the cost report within the prescribed period may result in suspension of reimbursement until the cost report is filed.
Providers will submit all required hospital cost reports and budgets In accordance with Medicare Principles of Reasonable Cost Reimbursement Identified In 42 CFR, Part 413 . All cost settlements will be made using these principles.
Revenue Code | Revenue Code Description |
114 | Inpatient Psychiatric Hospital only |
124 | Residential Treatment Center only |
128 | Sexual Offender Program only |
129 | Residential Treatment Unit only |
TBD | Facility-Based Community Reintegration Program only |
Medicaid (IViedical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining medical care witliin tlie guidelines specified in Section I of this manual. Rehabilitative Services for Persons with Mental Illness (RSPMI) are covered by Medicaid when provided to eligible Medicaid beneficiaries by enrolled providers.
RSPMI may be provided to eligible Medicaid beneficiaries at all provider facility certified sites. Acceptable allowable places of service are found in the service definitions located in Section 252.110.
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
Medicaid (Arkansas IVIedical Assistance Program) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Reimbursement will be made for allowed services rendered by a Medicaid enrolled provider within the Medicaid Program limitations as outlined in Section II of this manual.
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
Medicaid (IVIedical Assistance) is designed to assist eligible Arkansas Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section t of this manual. Substance Abuse Treatment Services (SATS) are covered by Arkansas Medicaid when provided to eligible Arkansas Medicaid beneficiaries by enrolled providers.
SATS may be provided to eligible Arkansas Medicaid beneficiaries at all provider facility certified sites. Allowable places of service are found in Section 252.200.
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
Professionals Who Provide School-Based Mental Health Services
School-Based Mental Health Services provider employees and contractors will provide services only in those areas in which they are licensed or credentialed.
School-Based Mental Health Services provider employees and contractors will be under the supervision and jurisdiction of the school district and/or ESC and will provide services twelve months of each year.
School district and Educational Services Cooperative (ESC) mental health provider employee and contractor requirements are as follows:
NOTE: A licensed certified social worker employed or contracted with the school
district or ESC may not be enrolled in the Targeted Case Management (TCM) Program. He or she must choose only one of these programs in which to participate.
NOTE: A licensed certified social worker employed or contracted with the school
district or ESC may not be enrolled in the Targeted Case Management (TCM) Program. He or she must choose only one of these programs in which to participate.
including a master's degree from an accredited educational institution recognized by the Arkansas Board of Examiners in Psychology as maintaining satisfactory standards or, in lieu tinereof, such training and experience as the Board shall consider equivalent.
Medicaid (Arkansas Medical Assistance Program) is designed to assist eligible beneficiaries in obtaining medical care within the guidelines specified in Section I of the manual. Reimbursement will be made for allowed services rendered by a Medicaid-enrolled school-based provider within the Medicaid Program limitations as outlined in this manual.
Each beneficiary who receives School-Based Mental Health Services can receive a limited amount of services. Once those limits are reached, a Primary Care Physician (PCP) referral or Patient-Centered Medical Home (PCMH) approval will be necessary to continue treatment. This referral or approval must be retained in the beneficiary's medical record.
A beneficiary can receive three (3) School-Based Mental Health Services before a PCP/PCMH referral is necessary. No services will be allowed to be provided without appropriate PCP/PCMH referral. The PCP/PCMH refen-al must be kept in the beneficiary's medical record.
The Patient-Centered Medical Home (PCMH) will be responsible for coordinating care with a beneficiary's PCP or physician for School-Based Mental Health Services. Medical responsibility for beneficiaries receiving School-Based Mental Health Services shall be vested in a physician licensed in Arkansas.
The PCP refen-al or PCMH authorization for School-Based Mental Health Services will serve as the prescription for those services.
See Section I of this manual for the PCP procedures. A PCP referral is generally obtained prior to providing service to Medicaid-eligible children. However, a PCP is given the option of providing a referral after a service is provided. If a PCP chooses to make a referral after a service has been provided, the referral must be received by the SBMH provider no later than 45 calendar days after the date of service. The PCP has no obligation to give a retroactive referral.
The SBMH provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral is received.
The School-Based Mental Health Services program consists of a range of mental health diagnostic, therapeutic, rehabilitative or palliative services provided by the employees and contractors described in Section 202.100 of this manual to Medicaid-eligible beneficiaries (including ARKids B) under age twenty-one (21) suffering from psychiatric conditions as described in the cun-ent allowable American Psychiatric Association Diagnostic and Statistical Manual (DSM).
Medicaid-covered school-based mental health services may be provided only when:
The following are non-covered School-Based Mental Health Services:
"Inpatient" means a patient who has been admitted to a medical institution on recommendation of a physician or dentist and is receiving room, board and professional services in the institution on a continuous 24-hour-a-day basis, or who is expected by the institution to receive room, board and professional services for a 24-hour period or longer even though it later develops that the patient dies, is discharged or is transfen-ed to another facility and does not actually stay in the institution for 24 hours.
See E. above for definition of inpatient.
Outpatient Services
Fifteen-minute units, unless otherwise stated.
Outpatient Behavioral Health Services must be billed on a per-unit basis, as reflected in a daily total, per beneficiary, per service.
One (1) unit = | 8-24 minutes |
Two (2) units = | 25-39 minutes |
Three (3) units = | 40-49 minutes |
Four (4) units = | 50-60 minutes |
Time spent providing services for a single beneficiary may be accumulated during a single, 24-hour calendar day. Providers may accumulatively bill for a single date of service, per beneficiary, per Outpatient Behavioral Health service. Providers are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Outpatient Behavioral Health service, based on the established procedure codes. No rounding is allowed.
The sum of the days' time, in minutes, per service will detennine how many units are allowed to be billed. That number must not be exceeded. The total number of minutes per service must be compared to the following grid, which detemiines the number of units allowed.
One (1) unit = | &-24 minutes |
Two (2) units = | 25-39 minutes |
Three (3) units = | 40-49 minutes |
Four (4) units = | 50-60 minutes |
In a single-claim transaction, a provider may bill only for service time accumulated within a single day for a single beneficiary. There is no "carryover" of time from one day to another or from one beneficiary to another,
Documentation in the beneficiary's record must reflect exactly how the number of units is determined.
No more than four (4) units may be billed for a single hour per beneficiary or provider of the service.
Refer to Section 272.100 of this manual for descriptions of procedure codes that are reimbursable by Arkansas Medicaid for School-Based Mental Health providers.
The Utilization Review Section of the Arl[LESS THAN]ansas Medicaid Program has the responsibility for assuring quality medical care for its beneficiaries along with protecting the integrity of both state and federal funds supporting the Medical Assistance Program.
The Division of Medical Services (DMS) of the Ari[LESS THAN]ansas Department of Human Services (DHS) has contracted with an independent contractor to perfomi on-site inspections of care (IOC) and retrospective reviews of outpatient mental health services provided by Outpatient Behavioral Health Services providers. View or print current contractor contact information. The reviews are conducted by licensed mental health professionals and are based on applicable federal and state laws, rules and professionally recognized standards of care.
The Division of IVledical Services (DI\/1S) of tine Arkansas Department of Human Services has contracted with a Quality Improvement Organization (QIO) or QlO-like organization to perfomi retrospective (post-payment) reviews of outpatient mental health sen/ices provided by Outpatient Behavioral Health providers. View or print current contractor contact information.
The reviews will be conducted by licensed mental health professionals who will examine the medical record for compliance with federal and state laws and regulations.
If an adverse decision is received, the beneficiary may request a fair hearing of the denial decision.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services within thirty days of the date on the letter explaining the denial of services.
The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate the recoupment process for all claims that the current contractor has denied because the records submitted do not support the claim of medical necessity.
Ari[LESS THAN]ansas Medicaid will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid beneficiary name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.
The following is a list of covered services available in the School-Based Mental Health Sen/ices Program. Practitioners enrolled as school-based mental health services provider personnel may provide the services on this list according to their scope of practice as identified by the licensure requirements.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
90791 | Psychiatric diagnostic evaluation (with no medical services) |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Mental Health Diagnosis is a clinical service for the purpose of determining the existence, type, nature and appropriate treatment of a mental illness or related disorder as described in the current allowable DSM. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostic process may include, but is not limited to, a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face component and will serve as the basis for documentation of modality and issues to be addressed (Plan of Care). Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. | * Date of service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * Presenting problem(s), history of presenting problem(s) including duration, intensity and response(s) to prior treatment * Culturally- and age-appropriate psychosocial history and assessment * Mental status/clinical observations and impressions * Current functioning plus strengths and needs in specified life domains * DSM diagnostic impressions to include all axes * Treatment recommendations * Goals and objectives to be placed in Plan of Care * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes (i.e. treatment plans, etc.). | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
APPLICABLE POPULATIONS | SPECIAL BILLJNG INSTRUCTIONS | |
Children and Youth | Outpatient Behavioral Health Services Providers cannot bill 90791 on same date of service | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | School-Based Mental Health | |
ALLOWABLE PERFORMING PROVIDER | PLACE OF SERVICE | |
* Licensed Certified Social Worker (LCSW) * Licensed Master Social Worker (LMSW) * Licensed Professional Counselor (LPC) * Licensed Associate Counselor (LAC) * Licensed School Psychology Specialist | 03 | |
(LSPS) | ||
* Licensed Psychological Examiner (LPE) | ||
* Psychologist | ||
* School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | ||
96101 | Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach®, WAIS®), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. | ||
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | ||
Psychological evaluation for personality assessment includes psychodiagnostic assessment of a beneficiary's emotional, personality, and psychopathology, e.g. MMPI, Rorschach®, and WAIS®. Psychological testing is billed per hour both face-time administering tests and time interpreting these tests and preparing the report. This service may reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the beneficiary. Medical necessity for this service is met when: the service is necessary to establish a differential diagnosis of behavioral or psychiatric conditions; * history and symptomatology are not readily attributable to a particular psychiatric diagnosis; or questions to be answered by the evaluation could not be resolved by a psychiatric/diagnostic interview, observation in therapy or an assessment for level of care at a mental health facility. | * Date of service * Start and stop times of actual encounter with beneficiary * Start and stop times of scoring, interpretation and report preparation * Place of service * Identifying information * Rationale for referral * Presenting problem(s) * Culturally- and age-appropriate psychosocial history and assessment * Mental status/clinical observations and impressions * Psychological tests used, results, and interpretations, as indicated * DSM diagnostic impressions to include all axes * Treatment recommendations and findings related to rationale for service and guided by test results * Staff signature/credentials/date of signature(s) | ||
NOTES I---------.-------------------------------------------------------------- | UNIT | BENEFIT LIMITS | |
60 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 8 | ||
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | ||
Children and Youth | |||
ALLOWED MODE{S) OF DELIVERY | TIER | ||
Face-to-face | School-Based Mental Health | ||
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | ||
* Licensed Psychological Examiner (LPE) * Psychologist | 03 | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90887 | Interpretation or explanation of results of psychiatric or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Interpretation of Diagnosis is a direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures or accumulated data. Services may include diagnostic activities and/or advising the beneficiary and his/ her family. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. | * Start and stop times of face to face encounter with beneficiary and/or parents or guardian * Date of service * Place of service * Participants present and relationship to beneficiary * Diagnosis * Rationale for and objective used that must coincide with the goals and objectives placed in Plan of Care * Participant(s) response and feedback * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS |
For beneficiaries under the age of 18, the time may be spent face-to-face with the beneficiary, the beneficiary and the parent(s) or guardian(s) or alone with the parent(s) or guardian(s). For beneficiaries over the age of 18, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian or significant other. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of |
Present
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
90847 | Family psychotherapy with patient present (conjoint psychotherapy) |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Marital/Family Behavioral Health Counseling with Beneficiary Present is a face-to-face treatment provided to one or more family members in the presence of a beneficiary. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. | Date of Service Start and stop times of actual encounter with beneficiary and spouse/family * Place of service Participants present and relationship to beneficiary * Diagnosis and pertinent interval history Brief mental status of beneficiary and observations of beneficiary with spouse/family Rationale for, and description of treatment used, that must coincide with the master treatment plan and improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family. * Beneficiary and spouse/family's response to treatment that includes cun-ent progress or regression and prognosis |
* Any changes indicated for the master treatment plan, diagnosis, or medication(s) Plan for next session, including any homework assignments and/or crisis plans Staff signature/credentials/date of signature HIPAA compliant release of Information, completed, signed and dated | |
NOTES | UNIT | BENEFIT LIMITS |
Natural supports may be included in these sessions if justified in service documentation. Only one beneficiary per family per therapy session may be billed. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | School-Based Mental Health | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Licensed Certified Social Worker (LCSW) * Licensed IVIaster Social Worker (LMSW) * Licensed Professional Counselor (LPC) * Licensed Associate Counselor (LAC) * Licensed School Psychology Specialist (LSPS) * Licensed Psychological Examiner (LPE) * Psychologist * School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2011.HA | Crisis intervention service, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Crisis Intervention is unsclieduled, immediate, short-term treatment activities provided to a Medicaid-eligible beneficiary wlio is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services are designed to stabilize the person in crisis, prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. (These activities include evaluating a Medicaid-eiigible beneficiary to determine if the need for crisis services is present.) | * Date of service * Start and stop time of actual encounter with beneficiary and possible collateral contacts with caregivers or informed persons * Place of service * Specific persons providing pertinent information in relationship to beneficiary * Diagnosis and synopsis of events leading up to crisis situation * Brief mental status and observations * Utilization of previously established psychiatric advance directive or crisis plan as pertinent to current situation OR rationale for crisis intervention activities utilized * Beneficiary's response to the intervention that Includes current progress or regression and prognosis * Clear resolution of the current crisis and/or plans for further services * Development of a clearly defined crisis plan or revision to existing plan * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS |
A psychiatric or behavioral crisis is defined as an acute situation in which an individual is experiencing a serious mental illness or emotional disturbance to the point that the beneficiary or others are at risk for imminent harm or in which to prevent significant deterioration of the beneficiary's functioning. This service can be provided to beneficiaries that have not been previously assessed or have not previously received behavioral health services. The provider of this service MUST complete a Mental Health Diagnosis (90791) within 7 days of provision of this service. If the beneficiary needs more time to be stabilized, this must be noted in the beneficiary's medical record and the Division of Medical Services Quality Improvement Organization (QIC) must be notified. | 15 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 72 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | ||
ALLOWED MODE(S) OF DELIVERY | |TIER _ ' | |
Face-to-face | School-Based Mental Health | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Licensed Certified Social Worker (LCSW) * Licensed Master Social Worker (LMSW) * Licensed Professional Counselor (LPC) * Licensed Associate Counselor (LAC) * Licensed School Psychology Specialist (LSPS) * Licensed Psychological Examiner (LPE) * Psychologist * School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90832 90834 90837 | 90832: psychotherapy, 30 min 90834: psychotherapy, 45 min 90837: psychotherapy, 60 min | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Individual Behavioral Health Counseling is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based with an emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse and maintain or improve level of functioning, and/or prevent deterioration. Additionally, tobacco cessation counseling is a component of this service. | * Date of service * Start and stop times of face-to-face encounter with beneficiary * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale and description of the treatment used that must coincide with objectives on the master treatment plan * Beneficiary's response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the master treatment plan, diagnosis or medication(s) * Plan for next individual therapy session, including any homework assignments and/or advanced psychiatric directive * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFITLIMITS |
Services provided must be congruent with the objectives and interventions articulated on the | 90832: 30 minutes 90834: 45 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE |
most recent treatment plan. Services must be consistent with established behavioral healthcare standards. Individual psychotherapy is not permitted with beneficiaries who do not have the cognitive ability to benefit from the service. | 90837: 60 minutes | BILLED: 90832:1 90834:1 90837: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 units |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | A provider may only bill one individual counseling/psychotherapy code per day per beneficiary. A provider cannot bill any other individual counseling/psychotherapy code on the same date of service for the same beneficiary. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | School-Based Mental Health | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE (POS) | |
* Licensed Certified Social Worker (LCSW) * Licensed Master Social Worker (LMSW) * Licensed Professional Counselor (LPC) * Licensed Associate Counselor (LAC) * Licensed School Psychology Specialist (LSPS) * Licensed Psychological Examiner (LPE) * Psychologist * School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
Outpatient Behavioral Health Services___________
Medicaid (i\4edical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Outpatient Behavioral Health Services are covered by Medicaid when provided to eligible Medicaid beneficiaries by enrolled providers.
Outpatient Behavioral Health Services may be provided to eligible Medicaid beneficiaries at all provider certified/enrolled sites. Allowable places of service are found in the service definitions located in Section 252, Section 253, Section 254 and Section 255 of this manual.
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program, and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP, and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting on July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018; and no Arkansas Medicaid payments will occur to any RSPMI, LMHP, or SATS provider for a service provided after June 30, 2018.
The Inpatient Psychiatric Services for Persons Under Age 21 program and manual will also be amended to ensure that continuity of care is maintained for beneficiaries under the Age of 21 needing Inpatient Psychiatric Services. Eligibility for entry into a residential setting requires adherence to appropriate Medicaid rules regarding that setting, which will be amended to require an Intensive Level Services Independent Assessment. The Independent Assessment will contain additional criteria and questions which will be asl[LESS THAN]ed based upon results from the Independent Assessment to determine eligibility for Inpatient Level Services. Acute inpatient psychiatric care will not require an Independent Assessment.
Behavioral Health Services
All behavioral health providers approved to receive Medicaid reimbursement for services to Medicaid beneficiaries must meet specific qualifications for their services and staff. Providers with multiple service sites must enroll each site separately and reflect the actual service site on billing claims.
Behavioral Health Providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Notification is not required when the list of covered health care practitioners remains unchanged from the previous notification.
QMS shall exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(a) and implementing regulations and may exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(b) and implementing regulations. The following factors shall be considered by DHS in determining whether sanction(s) should be imposed:
Services (DBHS)
In order to enroll into the Outpatient Behavioral Health Services Medicaid program as a Perfomiing Provider or Group for Counseling Services or a Behavioral Health Agency for Rehabilitation Level Services, all performing providers, provider groups, and business entities participating in the Medicaid Outpatient Behavioral Health Services (OBH) Program must be certified by the Division of Behavioral Health Services (DBHS), unless expressly exempted from this requirement. The DBHS Certification Rules for Providers of Outpatient Behavioral Health Services is located at http://humanservices.arlonsas.gov/dbhs/Paqes/dbhs docs.aspx.
Behavioral Health Agencies must have national accreditation that recognizes and includes all of the applicant's programs, services and service sites. Any outpatient behavioral health program service site associated with a hospital must have a free-standing behavioral health outpatient program national accreditation. Providers must meet all other DBHS certification requirements in addition to accreditation.
Behavioral Health Agencies with multiple service sites must apply for enrollment for each site. A cover letter must accompany the provider application for enrollment of each site that attests to their satellite status and the name, address and Arkansas Medicaid number of the parent organization.
A letter of attestation must be submitted to the Medicaid Enrollment Unit by the parent organization annually that lists the name, address and Arkansas Medicaid number of each site affiliated with the parent. The attestation letter must be received by Arkansas Medicaid no later than June 15 of each year.
Failure by the parent organization to submit a letter of attestation by June 15 each year may result in the loss of Medicaid enrollment. The Enrollment Unit will verify the receipt of all required letters of attestation by July 1 of each year. A notice will be sent to any parent organization if a letter is not received advising of the impending loss of Medicaid enrollment.
Outpatient Behavioral Health Services are limited to certified providers who offer core behavioral health services for the treatment and prevention of behavioral disorders. All performing providers, provider groups, and business entities participating in the Medicaid Outpatient Behavioral Health Services (OBH) Program must be certified by the Division of Behavioral Health Services (DBHS), unless expressly exempted from this requirement.
An Outpatient Behavioral Health Services provider must establish a site specific emergency response plan that complies with the DBHS Certification Rules for Providers of Outpatient Behavioral Health Services manual. Each agency site must have 24-hour emergency response capability to meet the emergency treatment needs of the Behavioral Health Services beneficiaries served by the site. The provider must implement and maintain a written policy reflecting the specific coverage plan to meet this requirement. An answering machine message to call 911 or report to the nearest emergency room in and of itself is not sufficient to meet the requirement.
Licensed performing providers as certified by DBHS must also maintain an Emergency Service Plan that complies with the DBHS Certification Rules for Providers of Outpatient Behavioral Health Services manual.
All Outpatient Behavioral Health Services providers must demonstrate the capacity to provide effective, equitable, understandable, and respectful quality care and sen/ices that are responsive to diverse cultural health beliefs and practices, prefen-ed languages, health literacy and other communication needs.
Each Behavioral Health Agency must establish and maintain a quality assurance committee that will meet quarterly and examine the clinical records for completeness, adequacy and appropriateness of care, quality of care and efficient utilization of provider resources. The committee must also comply with the DBHS Certification Rules for Providers of Outpatient Behavioral Health Services manual. Documentation of quality assurance committee meetings and quality improvement programs must be filed separately from the clinical records.
Each Outpatient Behavioral Health Services provider must ensure that they employ staff which is able and available to provide appropriate and adequate services offered by the provider. Behavioral Health staff members must provide services only within the scope of their individual licensure. The following chart lists the temriinology used in this provider manual and explains the licensure, certification and supervision that are required for each performing provider type.
PROVIDER TYPE | LICENSES | STATE CERTIFICATION REQUIRED ,;:. | SUPERVISION |
Certified Peer Support Specialist | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Certified Youtfi Support Specialist | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Certified Family Support Partner | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Qualified Behavioral Heaitli Provider -non-degreed | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Qualified Behavioral Health Provider -Bachelors | N/A | Yes, to provide services within a certified behavioral health agency | Required |
Independently Licensed Clinicians -Master's/Doctoral | Licensed Clinical Social Worker (LCSW) Licensed Marital and Family Therapist (LMFT) Licensed Psychologist (LP) Licensed Psychological Examiner - Independent (LPEI) Licensed Professional Counselor (LPC) | Yes, must be certified to provide services | Not Required |
Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | Licensed Clinical Social Worker (LCSW) Licensed Marital and Family Therapist (LMFT) Licensed Psychologist (LP) Licensed Psychological Examiner - Independent (LPEI) Licensed Professional Counselor (LPC) | Yes, must be certified to provide services | Not Required |
Non-independently Licensed Clinicians -Master's/Doctoral | Licensed Master Social Worker (LMSW) Licensed Associate Counselor (LAC) Licensed Psychological Examiner (LPE) Provisionally Licensed Psychologist (PLP) | Yes, must be supervised by appropriate Independently Licensed Clinician | Required |
Non-independently Licensed Clinicians - | Licensed Master Social Worker (LMSW) | Yes, must be supervised by appropriate | Required |
Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | Licensed Associate Counselor (LAC) Licensed Psychological Examiner (LPE) Provisionally Licensed Psychologist (PLP) | Independently Licensed Clinician and must be certified to provide services | |
Registered Nurse | Registered Nurse (RN) | No, must be a part of a certified agency | Required |
Advanced Practice Nurse (APN) | Adult Psychiatric Mental Health Clinical Nurse Specialist Child Psychiatric Mental Health Clinical Nurse Specialist Adult Psychiatric Mental Health APN Family Psychiatric Mental Health APN | No, must be part of a certified agency or have a Collaborative Agreement with a Physician | Collaborative Agreement with Physician Required |
Physician | Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) | No, must provide proof of licensure | Not Required |
The services of a medical records librarian are required. The medical records librarian (or person performing the duties of the medical records librarian) shall be responsible for ongoing quality controls, for continuity of patient care and patient traffic flow. The librarian shall assure that records are maintained, completed and preserved; that required indexes and registries are maintained and that statistical reports are prepared. This staff member will be personally responsible for ensuring that Information on enrolled patients is immediately retrievable, establishing a central records index, and maintaining service records in such a manner as to enable a constant monitoring of continuity of care.
When an Outpatient Behavioral Health Services provider files a claim with Arkansas Medicaid, the staff member who actually perfomed the service must be identified on the claim as the performing provider. This action is tal[LESS THAN]en in compliance with the federal Improper Payments Infonnation Act of 2002 (IPIA), Public Law 107-300 and the resulting Payment En-or Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).
As illustrated in the chart in § 211.200, certain Outpatient Behavioral Health perfomning providers are required to be certified by the Division of Behavioral Health Services (DBHS). The certification requirements for perfomiing providers are located on the DBHS website at http://humanservices.arkansas.gov/dbhs/Paaes/dbhs docs.aspx.
The Outpatient Behavioral Health Services provider shall be responsible for providing physical facilities that are structurally sound and meet all applicable federal, state and local regulations for adequacy of construction, safety, sanitation and health. These standards apply to buildings in which care, treatment or services are provided. In situations where Outpatient Behavioral Health Services are not provided in buildings, a safe and appropriate setting must be provided.
The Outpatient Behavioral Health Services provider may not refuse services to a Medlcaid-eligible beneficiary who meets the requirements for Outpatient Behavioral Health Services as outlined in this manual. If a provider does not possess the services or program to adequately treat the beneficiary's behavioral health needs, the provider must communicate this with the Care Coordination Entity for beneficiaries receiving Rehabilitation Services or the Patient-Centered Medical Home for beneficiaries receiving Counseling Services so that appropriate provisions can be made.
The Outpatient Behavioral Health Services Program provides care, treatment and services which are provided by a certified Behavioral Health Services provider to Medicaid-eligible beneficiaries that have a Behavioral Health diagnosis as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV and subsequent revisions).
Eligibility for services depends on the needs of the beneficiary. Counseling Level Services and Crisis Services can be provided to any beneficiary as long as the services are medically necessary. Beneficiaries will be deemed eligible for Rehabilitative Level Services and Intensive Level Services based upon the results of an Independent Assessment performed by an independent entity. The goal of the Independent Assessment is to determine the care, treatment, or services that will best meet the needs of the beneficiary initially and over time.
COUNSELING LEVEL SERVICES
Time-limited behavioral health services provided by qualified licensed practitioners in an outpatient-based setting for the purpose of assessing and treating mental health and/or substance abuse conditions. Counseling Services settings shall mean a behavioral health clinic/office, healthcare center, physician office, and/or school.
REHABILITATIVE LEVEL SERVICES
Home and community based behavioral health services with care coordination for the purpose of treating mental health and/or substance abuse conditions. Services shall be rendered and coordinated through a team based approach. A standardized Independent Assessment to determine eligibility and a Treatment Plan is required. Rehabilitative Level Services home and community based settings shall include services rendered in a beneficiary's home, community, behavioral health clinic/ office, healthcare center, physician office, and/ or school.
INTENSIVE LEVEL SERVICES
The most intensive behavioral health services for the purpose of treating mental health and/or substance abuse conditions. Services shall be rendered and coordinated through a team based approach. Eligibility for Intensive Level services will be determined by additional criteria and questions on the Independent Assessment based upon the results from the Independent Assessment to determine eligibility for Intensive Level Services. This level of care will be based upon a referral from a Behavioral Health Agency that is providing Rehabilitative Services to a beneficiary or the Independent Care Coordination entity. Residential treatment services are available-if deemed medically necessary and eligibility is detennined by way of the additional criteria and questions on the standardized Independent Assessment.
Prior to continuing provision of Counseling Level Services, the provider must provide documentation of the medical necessity of Outpatient Behavioral Health Counseling Services. This documentation must be made part of the beneficiary's medical record. The documentation of medical necessity is a written assessment that evaluates the beneficiary's mental condition and, based on the beneficiary's diagnosis, detemiines whether treatment in the Outpatient Behavioral Health Counseling Services program is appropriate. If a beneficiary is determined to be eligible for Rehabilitation Level Services or Intensive Level Services, the documentation of medical necessity of services will be met by the standardized Independent Assessment and the Psychiatric Diagnostic Assessment that will be required for beneficiaries in that level of care.
The documentation of medical necessity of Counseling Level Outpatient Behavioral Health Services must be completed by a mental health professional qualified by licensure and experienced in the diagnosis and treatment of behavioral health.
Each beneficiary that receives only Outpatient Behavioral Health Counseling Level Services can receive a limited amount of Counseling Level Services. Once those limits are reached, a Primary Care Physician (PCP) referral or PCMH approval will be necessary to continue treatment. This referral or approval must be retained in the beneficiary's medical record. The requirements for this are located in § 217.100 of this manual.
A standardized intake must be completed prior to provision of Counseling Level Services in the Outpatient Behavioral Health Services program. This standardized intake is a part of the Mental Health Diagnosis service (CPT® Code 90791) that is required for provision of Counseling Level Services. This standardized intake will assist providers in determining services needed and desired outcomes for the beneficiary. The standardized intake must be placed in the medical record of the beneficiary and must be signed by appropriately licensed providers.
A standardized Independent Assessment will determine eligibility for Rehabilitative Level Services and Intensive Level Services. The standardized Independent Assessment must be performed by an independent entity.
A standardized Independent Assessment of the beneficiary is required to determine eligibility and need for Rehabilitative Level Services. Any beneficiary may refuse to participate in the standardized Independent Assessment when contacted, and refusal will be noted. If the beneficiary chooses not to participate in the standardized Independent Assessment, he or she will not be eligible to access Rehabilitative Level Services.
Additional criteria and questions asked based upon results from the Independent Assessment will determine eligibility for Intensive Level Services. If the beneficiary chooses not to participate in the additional standardized Independent Assessment, he or she will not be eligible to access Intensive Level Services.
The standardized Independent Assessment must be conducted at least every 12 months by an Independent Assessor in consultation with the beneficiary and anyone the beneficiary requests to participate in the standardized Independent Assessment. The standardized Independent Assessment will also take into consideration information obtained from behavioral health service providers that are providing services to the beneficiary.
A beneficiary must be referred to the Independent Assessment entity to evaluate whether the beneficiary meets the eligibility criteria for Rehabilitative Level Services or Intensive Level Services. The following are allowable methods of referral to receive a standardized Independent Assessment for detennination of eligibility for Rehabilitative Level Services or Intensive Level Services:
A re-assessment can be requested by the direct behavioral health service provider or the Care Coordination entity if the direct behavioral health service provider or Care Coordination entity determines the beneficiary's needs are not being met or the beneficiary is not benefitting from the Rehabilitative Level Services or Intensive Level Services being provided.
The Independent Assessor will contact the beneficiary to be assessed within 48 hours of referral and will complete the face-to-face assessment within 14 calendar days. For identified priority populations, the independent assessor will contact the beneficiary to be assessed within 24 hours of notification from the beneficiary's provider and will complete the assessment within 7 days of the notification. Examples of priority population include, but is not to be limited to:
The following beneficiaries will be deemed presumptively eligible for receipt of Rehabilitative Level Services and Therapeutic Communities in Intensive Level Services prior to the completion of an independent assessment. These populations are included in the priority population to receive an independent assessment within 7 days of notification of need for an independent assessment.
Eligibility for Rehabilitative Level Services is determined by a standardized Independent Assessment.
Based upon the standardized Independent Assessment, a Treatment Plan must be developed for all beneficiaries receiving Rehabilitative Level Services. The beneficiary will be supported in Treatment Plan development by a care coordinator and allowed the ability to choose who they want to participate in the development of the Treatment Plan. In the case of children Under Age18, the parents participation (or legal guardian, DCFS, DYS, caretaker) must be included in the development of the Treatment Plan.
If the beneficiary (or the person chosen by the beneficiary to participate in the Treatment Plan development) does not participate in the Treatment Plan development, they will not be eligible to receive Rehabilitative Level Services.
Individuals that do not qualify for Rehabilitative Level Services can continue to be provided Counseling Level Services.
Additional criteria and questions asked based upon results from the Independent Assessment will detemriine eligibility for Intensive Level Sen/ices.
Eligibility for entry into a residential setting requires adherence to appropriate Medicaid rules regarding that residential setting. Eligibility for Therapeutic Communities requires that an Individualized Treatment Plan be developed for the beneficiary. The beneficiary will be supported in Treatment Plan development by a care coordinator and allowed the ability to choose who they want to participate in the development of the Individualized Treatment Plan.
If the beneficiary (or the person chosen by the beneficiary to participate in the Treatment Plan development) does not participate in the Individualized Treatment Plan development, they will not be eligible to receive Intensive Level Services.
Individuals that do not qualify for Intensive Level Services can continue to be provided Counseling Level Services, and if they qualify based upon the standardized Independent Assessment, Rehabilitative Level Services.
Any time while receiving services, the beneficiary may opt out of Rehabilitative Level Services or Intensive Level Services. When determined to be eligible to receive Rehabilitative Level Services or Intensive Level Services, the beneficiary will have the option to choose a provider of those services. The Independent Assessment entity will provide eligible beneficiaries a list of all current providers of Rehabilitative Level Services and Intensive Level Services.
Outpatient Behavioral Health Providers provide Counseling Level Services by qualified licensed practitioners in an outpatient based setting for the purpose of assessing and treating behavioral health conditions. Counseling Level Services outpatient based setting shall mean services rendered in a behavioral health clinic/ office, healthcare center, physician office, and/or school. The performing provider must provide services only within the scope of their individual licensure. Services available to be provided by Counseling Level Services providers are listed in Section 252.110 of the Outpatient Behavioral Health Services manual.
months & Parent/Caregiver)
Outpatient Behavioral Health Providers may provide dyadic treatment of beneficiary's age 0-47 months and the parent/caregiver of the eligible beneficiary. A prior authorization will be required for all dyadic treatment services (the Mental Health Diagnosis and Interpretation of Diagnosis DO NOT require a prior authorization). All perfonning providers of parent/caregiver and child Outpatient Behavioral Health Services MUST be certified by DBHS to provide those services.
Providers will diagnose children through the age of 47 months based on the DC: 0-3R. Providers will then crosswalk the DC: 0-3R diagnosis to a DMS diagnosis. Specified V codes will be allowable for this population.
Certified Rehabilitative Level Services providers make available Rehabilitative Level Services to qualified beneficiaries based upon the standardized Independent Assessment. A Behavioral Health Agency is not required to offer all services in all levels of care.
Certified Intensive Level Services providers make available Intensive Level Services to qualified beneficiaries based upon the Intensive Level Services standardized Independent Assessment. A Behavioral Health Agency is not required to offer all services in all levels of care.
Each beneficiary that receives only Counseling Level Services in the Outpatient Behavioral Health Services program can receive a limited amount of Counseling Level Services. Once those limits are reached, a Primary Care Physician (PCP) referral or PCMH approval will be necessary to continue treatment. This referral or approval must be retained in the beneficiary's medical record.
A beneficiary can receive three (3) Counseling Level services before a PCP/PCMH referral is necessary. No services will be allowed to be provided without appropriate PCP/PCMH referral. The PCP/PCMH must be kept in the beneficiary's medical record.
The Patient Centered Medical Home (PCMH) will be responsible for coordinating care with a beneficiary's PCP or physician for Counseling Level Services. Medical responsibility for beneficiaries receiving Counseling Level Services shall be vested in a physician licensed in Arkansas.
Beneficiaries receiving Rehabilitative Level Services or Intensive Level Services will have care coordination available through the Independent Assessment/Care Coordination Entity. Beneficiaries receiving Rehabilitative Level Services or Intensive Level Services will have their care managed by Independent Assessment/Care Coordination Entity.
The PCP referral or PCMH authorization for Counseling Level Services will serve as the prescription for those services.
Verbal referrals from PCPs or PCMHs are acceptable to Medicaid as long as they are documented in the beneficiary's chart as described in Section 171.410.
See Section I of this manual for an explanation of the process to obtain a PCP referral.
A Treatment Plan is required for beneficiaries who are determined to be qualified for Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level
Services through the standardized Independent Assessment. The Treatment Plan should build upon the information from any Behavioral Health provider and infonnation obtained during the standardized Independent Assessment. Beneficiaries receiving only Counseling Level Services do NOT require a Treatment Plan and providers will not be reimbursed for completion of a Treatment Plan for beneficiaries receiving only Counseling Level Services. However, the provider must provide documentation of the medical necessity of Counseling Level Services. This documentation must be made part of the beneficiary's medical record. The documentation of medical necessity is a written assessment that evaluates the beneficiary's mental condition and, based on the beneficiary's diagnosis, determines whether treatment in the Outpatient Behavioral Health Services Program is appropriate.
A Treatment Plan is required for beneficiaries who are determined to be qualified for Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services. The Treatment Plan must reflect services to address areas of need identified during the standardized Independent Assessment. The Treatment Plan must be included in the beneficiary's medical record and contain a written description of the treatment objectives for that beneficiary. It also must describe:
The Treatment Plan for a beneficiary that is eligible for Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services must be completed by a mental health professional within 14 calendar days of the beneficiary entering care (first billable service) at a Rehabilitative Level Services or Therapeutic Communities certified Behavioral Health Agency. Subsequent revisions in the master treatment plan will be approved in writing (signed and dated) by the mental health professional and must occur at least every 90 days.
The Treatment Plan should be based on the beneficiary's (or the parents' or guardians' if the beneficiary is under the age of 18) articulation of the problems or needs to be addressed in treatment and the areas of need identified in the standardized Independent Assessment. Each problem or need must have one or more clearly defined behavioral goals or objectives that will allow the beneficiary, family members, provider and others to assess progress toward achievement of the goal or objective. For each goal or objective, the Treatment Plan must specify the treatment intervention(s) detemriined to be medically necessary to address the problem or need and to achieve the goal(s) or objective(s).
For all beneficiaries assessed to be qualified for and receiving Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services, the Treatment Plan must be periodically reviewed in order to determine the beneficiary's progress toward the treatment and care objectives, the need for the services provided and the enrolled beneficiary's continued participation. The reviews must be performed on a regular basis (at least every 180 calendar days), documented in detail in the enrolled beneficiary's medical record, kept on file and made available as requested for state and federal purposes. Without a change in eligibility for services based upon the standardized Independent Assessment, more frequent changes to a beneficiary's treatment plan will not be reimbursed by Arkansas Medicaid.
The standardized Independent Assessment must occur annually, which means that the infomiation from the standardized Independent Assessment must be updated annually for all beneficiaries assessed to be qualified for and receiving Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services.
The review of the Treatment Plan must reflect the beneficiary's, or in the case of a beneficiary under the age of 18, the parent's or guardian's, assessment of progress toward meeting treatment goals or objectives and their level of satisfaction with the treatment services provided. Problems, needs, goals, objectives, strengths and supports should be revised based on the progress made, barriers encountered, changes in clinical status and any other new infomnation. The beneficiary, the parent or the guardian must be provided an opportunity to express comments about the Treatment Plan and a space on the treatment plan fomn to record these comments and their level of satisfaction with the services provided. The review of the Treatment Plan must also reflect addressing additional areas of need identified in the required annual standardized Independent Assessment.
Covered outpatient services include a broad range of services to Medicaid-eligible beneficiaries. Beneficiaries eligible for Rehabilitative Level Services and Therapeutic Communities/Planned Respite in Intensive Level Services shall be served with an array of treatment services outlined on their Treatment Plan in an amount and duration designed to meet their medical needs.
For services that are not reimbursed on a per diem or per encounter rate, Medicaid has established daily benefit limits for all services. Beneficiaries will be limited to a maximum of eight hours per 24 hour day of Outpatient Behavioral Health Services. Beneficiaries will be eligible for an extension of the daily maximum amount of services based on a medical necessity review by the contracted utilization management entity (See Section 231.000 for details regarding extension of benefits).
Outpatient Behavioral Health telemedicine services are interactive electronic transactions performed "face-to-face" in real time, via two-way electronic video and audio data exchange.
Reimbursement for telemedicine services is only available when, at a minimum, the Arkansas Telehealth Network (ATN) recommended audio video standards for real-time, two-way interactive audiovisual transmissions are met. Those standards are:
Providers who provide telemedicine services for Medicaid-eligible beneficiaries must be able to link or connect to the Arkansas Telehealth Network to ensure HIPAA compliance. Sites providing reimbursable telemedicine services to Medicaid-eligible beneficiaries are required to demonstrate the ability to meet the ATN standards listed above. A site must be certified by ATN before telemedicine services can be conducted. ATN will conduct site visits at initial start-up to ensure that all standards are met and to certify each telemedicine site. ATN will view connectivity statistics in order to ensure that appropriate bandwidth is being utilized by sites and will conduct random site visits to ensure that providers continue to meet all recommended standards and guidelines.
The Arkansas licensed mental health professional may provide certain treatment services from a remote site to the Medicaid-eligible beneficiary who is located in a mental health clinic setting. There must be an employee of the clinic immediately available to the beneficiary when the beneficiary is receiving services provided via telemedicine. Refer to Section 256.200 for billing instructions.
The perfomiing provider of telemedicine services practicing within the scope of their licensure MUST:
All providers participating in the provision of services via telemedicine must meet all applicable standards and rules enacted by the appropriate licensing authority. The above does not supersede any of the licensing board's authority.
The following services may be provided via telemedicine by an Arkansas licensed mental health professional to Medicaid-eligible beneficiaries underage 21 and Medicaid-eligible beneficiaries age 21 and over:
The following services may be provided via telemedicine by an Arkansas licensed mental health professional to Medicaid-eligible beneficiaries age 21 and over:
The following services may be provided to residents of nursing homes and ICF/IID facilities who are Medicaid eligible when the services are prescribed according to policy guidelines detailed in this manual:
Services provided to nursing home and ICF/IDD residents may be provided on- or off-site from the provider if allowable per the service definition. Some services may be provided in the Long-Temi Care (LTC) facility, if necessary.
"Inpatient" means a patient who has been admitted to a medical institution on recommendation of a licensed practitioner authorized to admit patients; and who is receiving room, board and professional services in the institution on a continuous 24-hour-a-day basis; or who is expected by the institution to receive room, board and professional services for 24 hours or longer.
Inpatient hospital visits are Medicaid covered only for board certified or board eligible psychiatrists when the visit is necessary to evaluate, treat, or stabilize a psychiatric diagnosis which is secondary to the actual hospital admission. Each attending physician is limited to billing one day of care for an inpatient hospital Medicaid covered day, regardless of the number of hospital visits made by the physician. Rehabilitative Level Services/Intensive Level Services are not allowed to be billed for a beneficiary in an inpatient setting.
A "Medicaid covered day" is defined as a day for which the patient is Medicaid eligible, the patient's inpatient benefit limit has not been exhausted, the patient's inpatient stay is medically necessary, the day is not part of a hospital stay for a non-payable procedure or non-authorized procedure and the claim is filed on time. (See Section III of this manual for information regarding "Timely Filing.")
There is no inpatient benefit limit for Medicaid-eligible individuals under age 21. The benefit limit for general and rehabilitative hospital inpatient services is 24 paid inpatient days per state fiscal year (July 1 through June 30) for Medicaid beneficiaries aged 21 and older. Effective October 1, 2014 inpatient days beyond 24 will be reimbursed at $400.00 per day. This is a prospective per diem rate and will not be included in the cost settlement.
The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient, general and rehabilitative hospitals, both in state and out of state. The MUMP does not apply to lengths of stay in psychiatric facilities.
Lengths-of-stay determinations are made by the Quality Improvement Organization (QIO) under contract with the Arkansas Medicaid Program.
MUMP procedures are detailed in tlie following sections of this manual:
If a patient is transferred from one hospital to another, the receiving facility must contact the QIO under contract with the Arkansas Medicaid Program within 24 hours of admitting the patient to certify the inpatient stay. If admission falls on a weekend or holiday, the provider may contact the QIO under contract with the Arkansas Medicaid Program on the first working day following the weekend or holiday.
Reconsideration reviews of denied extensions may be expedited by faxing the medical record to the QIO under contract with the Arkansas Medicaid Program. The QIO under contract with the
Arkansas Medicaid Program will advise the iiospital of its decision by the next working day. View or print AFMC contact information.
A post payment review of a random sample is conducted on all admissions, including inpatient stays of four days or less, to ensure that medical necessity for the services is substantiated.
Outpatient behavioral health services are covered by l\/ledicaid only in the outpatient setting, except for inpatient hospital visits by board-certified psychiatrists.
The services and procedure codes available for billing are listed in Section 250.000 of this manual.
Services not covered under the Outpatient Behavioral Health Program include, but are not limited to:
Certified Behavioral Health Agencies which provide Rehabilitative Level Services and Therapeutic Communities/Planned Respite in Intensive Level Services are required to have relationships with a board certified or board eligible psychiatrist who provides appropriate supervision and oversight for all medical and treatment services for beneficiaries with behavioral health needs. A physician will supervise and coordinate all psychiatric and medical functions as indicated in the Treatment Plan that is required for beneficiaries receiving Rehabilitative Level Services or Intensive Level Services. Medical responsibility shall be vested in a physician licensed in Arkansas that signs the Treatment Plan of the beneficiary.
Certified Counseling Level Services providers must have relationships with a physician licensed in Arkansas in order to ensure psychiatric and medical conditions are monitored and addressed by appropriate physician oversight.
Medical supervision responsibility shall include, but is not limited to, the following:
The Psychiatric Assessment is a face-to-face psychodiagnostic assessment conducted by a licensed physician, preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under age 18). This service is provided to determine the existence, type, nature and most appropriate treatment of a behavioral health disorder. This service is not required for beneficiaries receiving only Counseling Level Services in the Outpatient Behavioral Health Services program. The Psychiatric Assessment is required for beneficiaries receiving Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services. This service can be provided to new patients and existing patients with differing requirements for each. This face-to-face psycho diagnostic assessment must be conducted by one of the following:
The PMHNP-BC must meet all of the following requirements:
A Psychiatric Assessment for a new patient must include:
A Psychiatric Assessment for an existing client must include:
The Psychiatric Assessment must contain sufficient detailed information to substantiate all diagnoses specified in the Treatment Plan (Treatment Plan is required for beneficiaries receiving Rehabilitative Level Services and Therapeutic Communities/Planned Respite in Intensive Level Services) and all problems or needs to be addressed on the Treatment Plan. The Psychiatric Assessment for existing patients must be performed, at a minimum, every 12 months. Only one (1) Psychiatric Assessment is allowed per State Fiscal Year.
Diagnosis and clinical impression is required in tiie terminology of ICD. 226.000 Documentation/Record Keeping Requirements
All Outpatient Behavioral Health Services providers must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of:
Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level in accordance with the staffing requirements found in Section 211.200.
All documentation must be available to representatives of the Division of Medical Services or Office of Medicaid Inspector General at the time of an audit. All documentation must be available at the provider's place of business. A provider will have 30 (thirty) days to submit additional documentation in response to a request from DMS or OMIG. Additional documentation will not be accepted after this 30 day period.
Each beneficiary that receives only Counseling Level Services can receive a limited amount of Counseling Level Services without a Primary Care Physician (PCP) referral or Patient-Centered Medical Home (PCMH) approval. Once those limits are reached, a PCP referral or PCMH approval will be necessary. This approval by the PCP or PCMH will serve as the prescription for Counseling Level Services in the Outpatient Behavioral Health Services program. Please see Section 217.100 for limits. Medicaid will not cover any service outside of the established limits without a current prescription signed by the PCP or PCMH.
Beneficiaries receiving Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services must have a signed prescription for services by a psychiatrist or physician. Medicaid will not cover any Rehabilitative Level Services or Therapeutic Communities/Planned Respite in Intensive Level Services without a current prescription signed by a psychiatrist or physician and eligibility detennined by a standardized Independent Assessment or Intensive Level Services Independent Assessment. The signed Treatment Plan will serve as the prescription for beneficiaries that are eligible for Rehabilitative Level Services and Therapeutic Communities/Planned Respite in Intensive Level Services.
Prescriptions shall be based on consideration of an evaluation of the enrolled beneficiary, the Independent Assessment, and goals and objectives of the Treatment Plan. The prescription of the services and subsequent renewals must be documented in the beneficiary's medical record.
The Utilization Review Section of the Arkansas Division of Medical Services has the responsibility for assuring quality medical care for its beneficiaries, along with protecting the integrity of both state and federal funds supporting the Medical Assistance Program.
The Division of Medical Services of the Arkansas Department of Human Services (DHS) has contracted with a third-party vendor to perfonn on-site Inspections of Care (IOC) and retrospective reviews of outpatient mental health services provided by Outpatient Behavioral Health Services providers. View or print current contractor contact information. The reviews are conducted by licensed mental health professionals and are based on applicable federal and state laws, rules and professionally recognized standards of care.
The on-site inspections of care of Outpatient Behavioral Health Services providers are intended to:
The review tool, process and procedures are available on the contractor's website at http://arkansas.valueoptions.com/provider/prv forms.htm. Any amendments to the review tool will be adopted under the Arkansas Administrative Procedures Act.
The provider will be notified no more than 48 hours before the scheduled amval of the inspection team. It is the responsibility of the provider to provide a reasonably comfortable place for the team to work. When possible, this location will provide reasonable access to the patient care areas and the medical records.
The contractor will review twenty (20) randomly selected cases during the IOC review. If a provider has fewer than 20 open cases, all cases shall be reviewed.
The review period shall be specified in the provider notification letter. The list of cases to be reviewed shall be given to the provider upon arrival or chosen by the IOC Team from a list for the provider site. The components of the records required for review include:
The provider is required to arrange interviews of Medicaid beneficiaries and family members as requested by the IOC team, preferably with the beneficiaries whose records are selected for review. If a beneficiary whose records are chosen for review is not available, then the interviews shall be conducted with a beneficiary on-site whose records are not scheduled for review. Beneficiaries and family members may be interviewed on-site, by telephone conference or both.
The Inspection of Care Team will conduct an exit conference summarizing their findings and recommendations. Providers are free to involve staff in the exit conference.
The contractor shall provide a written report of the IOC team's findings to the provider, DMS Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within 14 calendar days from the last day of on-site inspection. The written report shall clearly identify any area of deficiency and required submission of a corrective action plan.
The contractor shall provide a notification of either acceptance or requirement of directed correction to the provider, DIVIS Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within 14 calendar days of receiving a proposed corrective action plan and shall monitor corrective actions to ensure the plan is implemented and results in compliance.
All IOC reviews are subject to policy regarding Administrative Remedies and Sanctions (Section 150.000), Administrative Reconsideration and Appeals (Section 160.000) and Provider Due Process (Section 190.000). DMS will not voluntarily publish the results of the IOC review until the provider has exhausted all administrative remedies. Administrative remedies are exhausted if the provider does not seek a review or appeal within the time period permitted by law or rule.
The DMS/DBHS Wori[LESS THAN] Group (comprised of representatives from the Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the Division of Behavioral Health Services, the Office of Quality Assurance, the utilization review agency, as well as other units or divisions as required) will meet monthly to discuss IOC reports.
If a deficiency related to safety or potential risk to the beneficiary or others is found, then the utilization review agency shall immediately report this to the DMS Director (or the Director's designee).
The provider must submit a Corrective Action Plan designed to correct any deficiency noted in the written report of the IOC. The provider must submit the Corrective Action Plan to the contracted utilization review agency within 30 calendar days of the date of the written report. The contractor shall review the Con-ective Action Plan and fonward it, with recommendations, to the DMS Behavioral Health Unit, the Aricansas Office of Medicaid Inspector General and Division of Behavioral Health Services.
After acceptance of the Corrective Action Plan, the utilization review agency will monitor the implementation and effectiveness of the Corrective Action Plan via on-site review. DMS, its contractor(s) or both may conduct a desk review of beneficiary records. The desk review will be site-specific and not by organization. If it is determined that the provider has failed to meet the conditions of participation, DMS will detennine if sanctions are warranted.
monthly work group meeting: Clinical Director/Designee (at least a master's level mental health professional) or Executive Officer
The Division of Medical Services (DMS) of the Arkansas Department of Human Services has contracted with a Quality Improvement Organization (QIO) or QlO-like organization to perfomi retrospective (post payment) reviews of outpatient mental health services provided by Outpatient Behavioral Health providers. View or print current contractor contact information.
The reviews will be conducted by licensed mental health professionals who will examine the medical record for compliance with federal and state laws and regulations.
On a calendar quarterly basis, the contractor will select a statistically valid random sample from an electronic data set of all Outpatient Behavioral Health beneficiaries whose dates of service occurred during the three-month selection period. If a beneficiary was selected in any of the three calendar quarters prior to the current selection period, then they will be excluded from the sample and an alternate beneficiary will be substituted. The utilization review process will be conducted in accordance with 42 CFR § 456.23.
A written request for medical record copies will be mailed to each provider who provided services to the beneficiaries selected for the random sample along with instructions for submitting the medical record. The request will include the beneficiary's name, date of birth, Medicaid identification number and dates of service. The request will also include a list of the medical record components that must be submitted for review. The time limit for a provider to request reconsideration of an adverse action/decision stated in § 1 of the Medicaid Manual shall be the time limit to furnish requested records. If the requested infonnation is not received by the deadline, a medical necessity denial will be issued.
All medical records must be submitted to the contractor via fax, mail or ProviderConnect. View or print current contractor contact information. When faxing or mailing records, send them to the attention of "Retrospective Review Process." Records will not be accepted via email.
The record will be reviewed using a review tool based upon the promulgated Medicaid Outpatient Behavioral Health Services manual. The review tool is designed to facilitate review of regulatory compliance, incomplete documentation and medical necessity. All reviewers must have a professional license in nursing or therapy (LCSW, LMSW, LPE, LPC, RN, etc.). The reviewer will screen the record to determine whether complete information was submitted for review. If it is determined that all requested information was submitted, then the reviewer will review the documentation in more detail to determine whether it meets medical necessity criteria based upon the reviewer's professional judgment.
If a reviewer cannot determine that the services were medically necessary, then the record will be given to a psychiatrist for review. If the psychiatrist denies some or all of the services, then a denial letter will be sent to the provider and the beneficiary. Each denial letter contains a rationale for the denial that is record specific and each party is provided infonnation about requesting reconsideration review or a fair hearing.
The reviewer will also compare the paid claims data to the progress notes submitted for review. When documentation submitted does not support the billed sen/ices, the reviewer will deny the services which are not supported by documentation. If the reviewer sees a deficiency during a retrospective review, then the provider will be informed that it has the opportunity to submit infonnation that supports the paid claim. If the infonnation submitted does not support the paid claim, the reviewer will send a denial letter to the provider and the beneficiary. Each denial letter contains a rationale for the denial that is record-specific and each party is provided infonnation about requesting reconsideration review or a fair hearing.
Each retrospective review, and any adverse action resulting from a retrospective review, shall comply with the Medicaid Fairness Act. DMS will ensure that its contractor(s) is/are furnished a copy of the Act.
When an adverse decision is received, the beneficiary may request a fair hearing of the denial decision.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services within thirty days of the date on the letter explaining the denial of services.
Medicaid will accept electronic signatures provided the electronic signatures comply with Aricansas Code 25-31 -103 et seq.
The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate the recoupment process for all claims that the cun-ent contractor has denied because the records submitted do not support the claim of medical necessity.
Ari[LESS THAN]ansas Medicaid will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid beneficiary name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.
Tiie Division of JViedical Services contracts witli third-party vendor to complete tlie prior authorization and extension of benefit processes.
Prior Authorization is required for certain Outpatient Behavioral Health Services provided to Medicaid-eligible beneficiaries.
Prior Authorization requests must be sent to the DMS contracted entity to perform prior authorizations for beneficiaries under the age of 21 and for beneficiaries age 21 and over for services that require a Prior Authorization. Viev[GREATER THAN]/ or print current contractor contact information. Infomnation related to clinical management guidelines and authorization request processes is available at current contractor's website.
Procedure codes requiring prior authorization:
National Codes | Required Modifier | Service Title |
90832 90834 90837 | UK UK UK | Individual Behavioral Health Counseling - Age 3 Individual Behavioral Health Counseling - Age 3 Individual Behavioral Health Counseling - Age 3 |
90847 | UK | Marital/Family Behavioral Health Counseling with Beneficiary Present - Dyadic Treatment |
H2027 | UK | Psychoeducation - Dyadic Treatment |
H0015 | - | Intensive Outpatient Substance Abuse Treatment |
H2023 | - | Supportive Employment |
H0043 | - | Supportive Housing |
Extension of benefits is required for all services when the maximum benefit for the service is exhausted. Yearly service benefits are based on the state fiscal year running from July 1 to June 30. Extension of Benefits is also required whenever a beneficiary exceeds eight hours of outpatient services in one 24-hour day, with the exception of any service that is paid on a per diem basis.
Extension of benefit requests must be sent to the DMS contracted entity to perform extensions of benefits for beneficiaries. View or print current contractor contact information. Information related to clinical management guidelines and authorization request processes is available at current contractor's website.
Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying that the beneficiary is eligible for Arkansas Medicaid prior to rendering services.
Fifteen-Minute Units, unless othenvise stated
Outpatient Behavioral Health Services must be billed on a per unit basis, as reflected in a daily total, per beneficiary, per service.
One (1) unit = | 8-24 minutes |
Two (2) units = | 25 - 39 minutes |
Three (3) units = | 40 - 49 minutes |
Four (4) units = | 50 - 60 minutes |
Time spent providing services for a single beneficiary may be accumulated during a single, 24-hour calendar day. Providers may accumulatively bill for a single date of service, per beneficiary, per Outpatient Behavioral Health service. Providers are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Outpatient Behavioral Health service, based on the established procedure codes. No rounding is allowed.
The sum of the days' time, in minutes, per service will determine how many units are allowed to be billed. That number must not be exceeded. The total of minutes per service must be compared to the following grid, which detennines the number of units allowed.
One (1) unit = | 8-24 minutes |
Two (2) units = | 25 - 39 minutes |
Three (3) units = | 40 - 49 minutes |
Four (4) units = | 50 - 60 minutes |
In a single claim transaction, a provider may bill only for service time accumulated within a single day for a single beneficiary. There is no "carryover" of time from one day to another or from one beneficiary to another.
Documentation in the beneficiary's record must reflect exactly how the number of units is determined.
No more than four (4) units may be billed for a single hour per beneficiary or provider of the service.
NOTE: For services provided by a Qualified Behavioral Health Provider (QBHP), the accumulated time for the Outpatient Behavioral Health service, per date of service, is one total, regardless of the number of QBHPs seeing the beneficiary on that day. For example, two (2) QBHPs see the same beneficiary on the same date of service and provide Behavioral Assistance (CPT Code 2019). Thefirst QBHP spends a total of 10 minutes. Later in the day, another QBHP provides Behavioral Assistance (CPT Code 2019) to the same beneficiary and spends a total of 15 minutes. A total of 25 minutes of Behavioral Assistance (CPT Code 2019) was provided, which equals (two) 2 allowable units of service. Only one QBHP may be shown on the claim as the performing provider.
The length of time and number of units that may be billed for inpatient hospital visits are determined by the description of the service in Current Procedural Terminology (CPT).
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://www.medicaid.state.ar.us under the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Sen/ices is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel, established by the Director of the Division of Medical Services, which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Sen/ices.
Outpatient Behavioral Health Services providers use the CIVIS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary. View a CMS-1500 sample form.
Covered Behavioral Health Services are outpatient sen/ices. Specific Behavioral Health Services are available to inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine, and to nursing home and ICF/IDD residents. Outpatient Behavioral Health Services are billed on a per unit basis as listed. All services must be provided by at least the minimum staff within the licensed or certified scope of practice to provide the service.
Benefits are separated by Level of Service. A beneficiary can receive three (3) Counseling Level Services before a PCP/PCMH refen-al is necessary in the medical record.
Prior to reimbursement for Rehabilitative Level Services, a standardized Independent Assessment will determine eligibility and need for Rehabilitative Level Services. The standardized Independent Assessment must be performed by an independent entity.
Prior to reimbursement for Therapeutic Communities/Planned Respite in Intensive Level Services, a beneficiary must be eligible for Rehabilitative Level Services as detennined by the standardized Independent Assessment. The beneficiary must then also be determined by an Intensive Level Services Independent Assessment to be eligible for Therapeutic Communities.
ANY beneficiary that is to be placed into an inpatient psychiatric setting covered by the Arkansas Medicaid Inpatient Psychiatric Services for Under Age 21 program (excluding crisis or emergency admissions) must also follow the above process. The beneficiary must be eligible for Rehabilitative Level Services as determined by the standardized Independent Assessment. The beneficiary must then also be detennined by an Intensive Level Services Independent Assessment to be eligible for Inpatient Psychiatric Care or Inpatient Residential Care.
The allowable services differ by the age of the beneficiary and are addressed in the Applicable Populations section of the service definitions in this manual.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90832 90834 90837 90832, U7 - Telemedicine 90834, U7 - Telemedicine 90837, U7 - Telemedicine 90832, HF - Substance Abuse 90834, HF - Substance Abuse 90837, HF - Substance Abuse 90832, UK-Under Age 4 90834, UK-Under Age 4 90837, UK-Under Age 4 | 90832: psychotherapy, 30 min 90834: psychotherapy, 45 min 90837: psychotherapy, 60 min | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Individual Behavioral Health Counseling is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. The treatment service must reduce or alleviate Identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration. Additionally, tobacco cessation counseling is a component of this service. | * Date of Service * Start and stop times of face-to-face encounter with beneficiary * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale and description of the treatment used that must coincide with objectives on the master treatment plan * Beneficiary's response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next individual therapy session, including any homework assignments and/or advanced psychiatric directive * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Services provided must be congruent with the objectives and interventions articulated on the most recent treatment plan. Services must be consistent with established behavioral | 90832: 30 minutes 90834: 45 minutes 90837: 60 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: |
healthcare standards. Individual Psychotherapy Is not permitted with beneficiaries who do not have the cognitive ability to benefit from the service. This service is not for beneficiaries under the age of 4 except in documented exceptional cases. This service will require a Prior Authorization for beneficiaries under the age of 4. | 90832: 1 90834: 1 90837: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiary: 12 units between all 3 codes Rehabilitative/Intensive Level Beneficiary: 26 units between all 3 codes |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider may only bill one Individual Counseling / Psychotherapy Code per day per beneficiary. A provider cannot bill any other Individual Counseling / Psychotherapy Code on the same date of service for the same Ijeneficiary. For Counseling Level Beneficiaries, there are 12 total individual counseling visits allowed per year regardless of code billed for Individual Behavioral Health Counseling unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid. For Rehabilitative/Intensive Level Beneficiaries, there are 26 total individual counseling visits allowed per year regardless of code billed for Individual Behavioral Health Counseling unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid. | |
ALLOWED MODE(S) OF DELIVERY, | TIER , | |
Face-to-face Telemedicine (Adults and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE (POS) | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Providers of services for beneficiaries under age 4 must be trained and certified in specific evidence based practices to be | 03, 04, 11, 12, 49, 50. 53, 57, 71, 72 | |
reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90853 90853, HF - Substance Abuse | Group psychotherapy (other than of a multiple-family group) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Group Behavioral Health Counseling is a face-to-face treatment provided to a group of beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. | * Date of Service * Start and stop times of actual group encounter that includes identified beneficiary * Place of service * Number of participants * Diagnosis * Focus of group * Brief mental status and observations * Rationale for group counseling must coincide with master treatment plan * Beneficiary's response to the group counseling that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next group session, including any homework assignments * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This does NOT include psychosocial groups. Beneficiaries eligible for Group Outpatient -Group Psychotherapy must demonstrate the ability to benefit from experiences shared by others, the ability to participate in a group dynamic process while respecting the others' rights to confidentiality, and must be able to integrate feedback received from other group members. For groups of beneficiaries aged 18 | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be |
and over, the minimum number that must be served in a specified group is 2. The maximum that may be served in a specified group is 12. For groups of beneficiaries under 18 years of age, the minimum number that must be served in a specified group is 2. The maximum that may be served in a specified group is 10. A beneficiary must be 4 years of age to receive group therapy. Group treatment must be age and developmentally appropriate, (i.e., 16 year olds and 4 year olds must not be treated in the same group). Providers may bill for services only at times during which beneficiaries participate in group activities. | requested): Counseling Level Beneficiary: 12 units Rehabilitative/Intensive Level Beneficiary: 104 units | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one Group Behavioral Health Counseling / Community Group Psychotherapy encounter per day. For Counseling Level Beneficiaries, there are 12 total group behavioral health counseling visits allowed per year unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. For Rehabilitative/Intensive Level Beneficiaries, there are 104 total group behavioral health counseling visits allowed per year unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid. | |
ALLOWED MODE(S) OF DELIVERY | TIER '- | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician | 03,11,49.50,53,57.71,72 | |
Present
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90847 90847, HF - Substance Abuse 90847, UK - Dyadic Treatment * | Family psychotherapy (conjoint psychotherapy) (with patient present) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Marital/Family Behavioral Health Counseling with Beneficiary Present is a face-to-face | * Date of Service * Start and stop times of actual encounter with | |
treatment provided to one or more family members in the presence of a beneficiary. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. *Dyaciic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. Dyadic treatment must be prior authorized and is only available for beneficiaries in Tier 1. Dyadicinfant/Caregiver Psychotherapy is a behaviorally based therapy that involves improving the parent-child relationship by transforming the interaction between the two parties. The primary goal of Dyadic Infant/Parent Psychotherapy is to strengthen the relationship between a child and his or her parent (or caregiver) as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect and improving the child's cognitive, behavioral, and social functioning. This service uses child directed interaction to promote interaction between the parent and the child in a playful manner. Providers must utilize a national recognized evidence based practice. Practices include, but are not limited to, Child-Parent Psychotherapy (CPP) and Parent Child Interaction Therapy (PCIT). | beneficiary and spouse/family * Place of service * Participants present and relationship to beneficiary * Diagnosis and pertinent interval history * Brief mental status of beneficiary and observations of beneficiary with spouse/family * Rationale for, and description of treatment used that must coincide with the master treatment plan and improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family. * Beneficiary and spouse/family's response to treatment that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next session, including any homework assignments and/or crisis plans * Staff signature/credentials/date of signature * HIPAA compliant Release of Infomnation, completed, signed and dated | |
NOTES | UNIT | BENEFIT LIMITS |
Natural supports may be included in these sessions if justified in service documentation and if supported in the master treatment plan. Only one beneficiary per family per therapy session may be billed. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): |
Counseling Level Beneficiaries: 12 units Rehabilitative/Intensive Level Beneficiaries: 30 units between any use of procedure code 90847 and 90846 | ||
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one Marital / Family Behavioral Health Counseling with (or without) Patient Present / Home and Community Marital / Family Psychotherapy with (or without) Patient Present encounter per day. There are 12 total Marital/Family Behavioral Health Counseling with Beneficiary Present visits allowed per year unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid. The following codes cannot be billed on the Same Date of Service: 90849 - Multi-Family Behavioral Health Counseling | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | 03, 04. 11, 12, 49, 50, 53. 57, 71, 72 | |
Present
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90846 | Family psychotherapy (without the patient | |
90846, HF - Substance Abuse | present) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Marital/Family Behavioral Health Counseling without Beneficiary Present is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary. Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. | * Date of Service * Start and stop times of actual encounter with beneficiary and spouse/family * Place of service * Participants present and relationship to beneficiary * Diagnosis and pertinent interval history * Brief mental status of beneficiary and observations of beneficiary with spouse/family * Rationale for, and description of treatment used that must coincide with the master treatment plan and improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family. * Beneficiary and spouse/family's response to treatment that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next session, including any homework assignments and/or crisis plans * Staff signature/credentials/date of signature * HIPAA compliant Release of Information, completed, signed and dated | |
NOTES | UNIT | BENEFIT LIMITS |
Natural supports may be included in these sessions if justified in service documentation and if supported in the master treatment plan. Only one beneficiary per family per therapy session may be billed. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level |
Beneficiaries: 12 units Rehabilitative/Intensive Level Beneficiaries: 30 units between any use of procedure code 90847 and 90846 | ||
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one Marital / Family Behavioral Health Counseling with (or without) Beneficiary Present / Home and Community Marital / Family Psychotherapy with (or without) Beneficiary Present encounter per day. The following codes cannot be billed on the Same Date of Service: 90849 - Multi-Family Behavioral Health Counseling | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician | 03, 04, 11, 12, 49, 50, 53, 57, 71, 72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2027 H2027, U7 - Telemedicine H2027, UK - Dyadic Treatment* | Psychoeducational service; per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Psychoeducation provides beneficiaries and tiieir families with pertinent infomiation regarding mental illness, substance abuse, and tobacco cessation, and teaches problem-solving, communication, and coping skills to support recovery. Psychoeducation can be implemented in two formats: multifamily group and/or single family group. Due to the group format, beneficiaries and their families are also able to benefit from support of peers and mutual aid. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. *Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. Dyadic treatment must be prior authorized. Providers must utilize a national recognized evidence based practice. Practices include, but are not limited to, Nurturing Parents and Incredible Years. | * Date of Service * Start and stop times of actual encounter with spouse/family * Place of service * Participants present * Nature of relationship with beneficiary * Rationale for excluding the identified beneficiary * Diagnosis and pertinent interval history * Rationale for and objective used that must coincide with the master treatment plan and improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family. * Spouse/Family response to treatment that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next session, including any homework assignments and/or crisis plans * HIPAA compliant Release of Infomiation fonns, completed, signed and dated * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
infomiation to support the appropriateness of excluding the identified beneficiary must be documented in the service note and medical record. Natural supports may be included in these sessions when the nature of the relationship with the beneficiary and that support's expected role in attaining treatment goals is documented. Only one beneficiary per family per therapy session may be billed. | 15 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 48 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS |
Children, Youth, and Adults | A provider can only bill a total of 48 units of Psychoeducation / Home and Community Family Psychoeducation per SFY combined, regardless of code billed. The following codes cannot be billed on the Same Date of Service: 90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present 90847 - Home and Community Marital/Family Psychotherapy with Beneficiary Present 90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present 90846 - Home and Community Marital/Family Psychotherapy without Beneficiary Present |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face Telemedicine (Adults and Children) | Counseling |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
* Independently Licensed Clinicians -IVIaster's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | 03, 04,11,12, 49, 50, 53, 57, 71, 72 |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90849 90849, HF - Substance Abuse | Multiple-family group psychotherapy | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Multi-Family Behavioral Health Counseling is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others. Services are a more cost-effective alternative to Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. Additionally, tobacco cessation counseling is a component of this service. | * Date of Service * Start and stop times of actual encounter with spouse/family * Place of service * Participants present * Nature of relationship with beneficiary * Rationale for excluding the identified beneficiary * Diagnosis and pertinent interval history * Rationale for and objective used to improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family. * Spouse/Family response to treatment that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Plan for next session, including any homework assignments and/or crisis plans * HIPAA compliant Release of Infonnation forms, completed, signed and dated * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
May be provided independently if patient is being treated for substance abuse diagnosis only. Comorbid substance abuse should be provided as integrated treatment utilizing Family Psychotherapy. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | There are 12 total Multi-Family Behavioral Health Counseling visits allowed per year. The following codes cannot be billed on the Same Date of Service: 90887 - Interpretation of Diagnosis 90887 - Interpretation of Diagnosis, Telemedicine | |
ALLOWED MODE(S) OF DELIVERY * ' | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician | 03,11,49,50,53,57.71,72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
90791 90791, U7 - Telemedicine 90791, UK - Dyadic Treatment * | Psychiatric diagnostic evaluation (with no medical services) |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Mental Health Diagnosis is a clinical service for the purpose of determining the existence, type, nature, and appropriate treatment of a mental illness or related disorder as described in the current allowable DSM. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostic process may include, but is not limited to: a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face component and will serve as the basis for documentation of modality and issues to be addressed (plan of care). Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. | * Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic fomnulation * Place of service * Identifying information * Referral reason * Presenting problem(s), history of presenting problem(s), including duration, intensity, and response(s) to prior treatment * Culturally and age-appropriate psychosocial history and assessment * Mental status/Clinical observations and impressions * Current functioning plus strengths and needs in specified life domains |
* DSM diagnostic impressions to include all axes * Treatment recommendations * Goals and objectives to be placed in Plan of Care * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes (i.e. treatment plans, etc.). This service can be provided via telemedicine to beneficiaries only ages 21 and above. *Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. A Mental Health Diagnosis will be required for all children through 47 months to receive services. This service includes up to four encounters for children through the age of 47 months and can be provided without a prior authorization. This service must include an assessment of: o Presenting symptoms and behaviors; o Developmental and medical history; o Family psychosocial and medical history; o Family functioning, cultural and communication patterns, and current environmental conditions and stressors; o Clinical interview with the primary caregiver and observation of the caregiver-infant relationship and interactive patterns; o Child's affective, language, cognitive, motor, sensory, self-care, and social ifunctioning. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | The following codes cannot be billed on the Same Date of Service: 90792 - Psychiatric Assessment | |
H0001 - Substance Abuse Assessment | ||
ALLOWED MODE(S) OF DELIVERY | ||
Face-to-face Telemedicine (Adults Only) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | ||
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | 03, 04, 11, 12, 49, 50, 53, 57, 71, 72 | |
CPT®/HCPCS PROCEDURE CODE ., . , | PROCEDURE CODE DESCRIPTION |
90887 90887. U7 - Telemedicine 90887, UK - Dyadic Treatment | Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient |
SERVICE DESCRIPTION {: | MINIMUM DOCUMENTATION REQUIREMENTS |
Interpretation of Diagnosis is a direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures, or accumulated data. Services may include diagnostic activities and/or advising the beneficiary and his/ her family. Consent fomns may be required for family or significant other involvement. Services must be congment with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. | * Start and stop times of face-to-face encounter with beneficiary and/or parents or guardian * Date of service * Place of service * Participants present and relationship to beneficiary * Diagnosis * Rationale for and objective used that must coincide with the master treatment plan or proposed master treatment plan or recommendations |
* Participant(s) response and feedback * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS |
For beneficiaries under the age of 18, the time may be spent face-to-face with the beneficiary; the beneficiary and the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For beneficiaries over the age of 18, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian or significant other. This service can be provided via telemedicine to beneficiaries ages 18 and above. This service can also be provided via telemedicine to beneficiaries ages 17 and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiary: 1 |
*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months& parent/caregiver. Interpretation of Diagnosis will be required for all children through 47 months to receive services. This service includes up to four encounters for children through the age of 47 months and can be provided without a prior authorization. The Interpretation of Diagnosis is a direct service that includes an interpretation from a broader perspective the history and information collected through the Mental Health Diagnosis. This interpretation Identifies and prioritizes the infant's needs, establishes a diagnosis, and helps to determine the care and services to be provided. | Rehabilitative/Intensive Level Beneficiary: 2 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | The following codes cannot be billed on the Same Date of Service: H2027 - Psychoeducation 90792 - Psychiatric Assessment H0001 - Substance Abuse Assessment This service can be provided via telemedicine to beneficiaries ages 18 and above. This service can also be provided via telemedicine to | |
beneficiaries ages 17 and under with documentation of parental or guardian Involvement during the service. This documentation must be included in the medical record. | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine Adults and Children | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider | 03, 04, 11, 12, 49, 50, 53, 57, 71, 72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0001 | Alcohol and / or drug assessment | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Substance Abuse Assessment is a service tiiat identifies and evaluates tlie nature and extent of a beneficiary's substance abuse condition using the Addiction Severity Index (AS!) or an assessment instrument approved by DBHS and DIVIS. The assessment must screen for and identify any existing co-morbid conditions. The assessment should assign a diagnostic impression to the beneficiary, resulting in a treatment recommendation and referral appropriate to effectively treat the condition(s) identified. | * Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * Presenting problem(s), history of presenting problem(s), including duration, intensity, and response(s) to prior treatment * Culturally and age-appropriate psychosocial history and assessment * Mental status/Clinical observations and impressions * Current functioning and strengths in specified life domains * DSM diagnostic impressions to include all axes * Treatment recommendations * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
The assessment process results in the assignment of a diagnostic impression, beneficiary recommendation for treatment regimen appropriate to the condition and situation presented by the beneficiary, initial plan (provisional) of care and referral to a service appropriate to effectively treat the condition(s) identified. If indicated, the assessment process must refer the beneficiary for a psychiatric consultation | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | The following codes cannot be billed on the Same Date of Service: 90887 - Interpretation of Diagnosis 90791 - Mental Health Diagnosis | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician | 03, 04,11.12, 49. 50, 53. 57. 71. 72 | |
XPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
96101 | Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities. personality and psychopathology. e.g. MMPI. Rorschach®, WAIS®). per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Psychological Evaluation for personality assessment includes psychodiagnostic assessment of a beneficiary's emotional. personality, and psychopathology. e.g.. MMPI, Rorschach®, and WAIS®. Psychological testing is billed per hour both face-time administering tests and time interpreting these tests and preparing the report. This service may reflect the mental abilities, aptitudes, interests. attitudes, motivation, emotional and personality characteristics of the beneficiary. Medical necessity for this service is met when: * the service is necessary to establish a differential diagnosis of behavioral or psychiatric conditions * history and symptomatology are not readily attributable to a particular psychiatric diagnosis * questions to be answered by the evaluation could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health facility | * Date of Service * Start and stop times of actual encounter with beneficiary * Start and stop times of scoring, interpretation and report preparation * Place of service * Identifying information * Rationale for referral * Presenting problem(s) * Culturally and age-appropriate psychosocial history and assessment * Mental status/Clinical observations and impressions * Psychological tests used, results, and interpretations, as indicated * DSM diagnostic impressions to include all axes * Treatment recommendations and findings related to rationale for service and guided by test results * Staff signature/credentials/date of signature(s) |
NOTES | UNIT | BENEFIT LIMITS |
60 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 8 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Licensed Psychologist (LP) * Licensed Psychological Examiner (LPE) * Licensed Psychological Examiner -Independent (LPEI) | 03,11,49,50,53,57,71,72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
99212, UB-Physician 99213, UB-Physician 99214, UB - Physician 99212, U7, UB - Physician, Telemedicine 99213 U7, UB - Physician, Telemedicine 99214 U7, UB - Physician, Telemedicine 99212, SA-APN 99213, SA-APN 99214, SA-APN 99212, U7, SA-APN, Telemedicine 99213, U7, SA - APN, Telemedicine 99214, U7, SA-APN, Telemedicine | 99212: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making 99213: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. 99214: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history, A detailed examination; Medical decision making of moderate complexity | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Pharmacologic Management is a service tailored to reduce, stabilize or eliminate psychiatric symptoms. This service includes evaluation of the medication prescription, administration, monitoring, and supervision and informing beneficiaries regarding medication(s) and its potential effects and side effects in order to make infonned decisions regarding the prescribed medications. Services must be congaient with the age, strengths, and accommodations necessary for disability and cultural framework. | * Date of Service * Start and stop times of actual encounter with beneficiary * Place of service (When 99 is used for telemedicine, specific locations of the beneficiary and the physician must be included) * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the master treatment plan * Beneficiary's response to treatment that includes current progress or regression and prognosis * Revisions indicated for the master treatment plan, diagnosis, or medication(s) * Plan for follow-up services, including any crisis plans * If provided by physician that is not a psychiatrist, then any off label uses of medications should include documented consult with the overseeing psychiatrist within 24 hours of the prescription being written * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Applies only to medications prescribed to address targeted symptoms as identified in the treatment plan. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Advanced Practice Nurse * Physician | 03, 04, 11, 12, 49, 50, 53. 57, 71, 72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
90792 90792, U7 - Telemedicine | Psychiatric diagnostic evaluation with medical services | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Psychiatric Assessment is a face-to-face psychodiagnostic assessment conducted by a licensed physician or Advanced Practice Nurse (APN), preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under age 18). This service is provided to determine the existence, type, nature, and most appropriate treatment of a behavioral health disorder. This service is not required for beneficiaries to receive Counseling Level Services. | * Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * Presenting problem (s), history of presenting problem(s), including duration, intensity, and response(s) to prior treatment * Culturally and age-appropriate psychosocial history and assessment * Mental status/Clinical observations and impressions * Current functioning and strengths in specified life domains * DSM diagnostic impressions to include all axes * Treatment recommendations * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes (i.e. treatment plans, etc.). This service is not required for beneficiaries receiving only Counseling Level Services in the Outpatient Behavioral Health Services program. The Psychiatric Assessment is required for beneficiaries receiving Rehabilitative Level Services or Therapeutic Communities in ntensive Level Services. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
APPLICABLE POPULATfONS | SPECIAL BiLLJNGlNSTRUCfIONS |
Children, Youth, and Adults Telemediclne (Adults and Children) | The following codes cannot be billed on the Same Date of Service: 90791 - Mental Health Diagnosis |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face | Counseling |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
* Advanced Practice Nurse * Physician | 03, 04,11,12, 49, 50. 53, 57, 71, 72 |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
S0220 | S0220: Treatment Plan |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Treatment Plan is a plan developed in cooperation with the beneficiary (or parent or guardian if under 18) to deliver specific mental health services to restore, improve, or stabilize the beneficiary's mental health condition. The Plan must be based on individualized service needs as identified in the completed Mental Health Diagnosis, independent assessment, and independent care plan. The Plan must include goals for the medically necessary treatment of identified problems, symptoms and mental health conditions. The Plan must identify individuals or treatment teams responsible for treatment, specific treatment modalities prescribed for the beneficiary, and time limitations for services. The plan must be congruent with the age and abilities of the beneficiary, client-centered and strength-based; with emphasis on needs as identified by the beneficiary and demonstrate cultural competence. | * Date of Service (date plan is developed) * Start and stop times for development of plan * Place of sen/ice * Diagnosis * Beneficiary's strengths and needs * Treatment goal(s) developed in cooperation with and as stated by beneficiary that are related specifically to the beneficiary's strengths and needs * Measurable objectives * Treatment modalities - The specific services that will be used to meet the measurable objectives * Projected schedule for service delivery, including amount, scope, and duration * Credentials of staff who will be providing the services * Discharge criteria * Signature/credentials of staff drafting the document and primary staff who will be delivering or supervising the delivery of the specific services/ date of signature(s) |
* Beneficiary's signature (or signature of parent, guardian, or custodian of beneficiaries under the age of 18)/ date of signature * Physician's signature indicating medical necessity/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This service may be billed when the beneficiary enters care and must be reviewed every ninety (90) calendar days or more frequently if there is documentation of significant acuity changes in clinical status requiring an update/change in the beneficiary's master treatment plan. It is the responsibility of the primary mental health professional to insure that all individuals working with the client have a clear understanding and work toward the goals and objectives stated on the treatment plan. | 30 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 2 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 4 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | Must be reviewed every 180 calendar days | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS * Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician | PLACE OF SERVICE 03, 04, 11, 12,14, 33, 49, 50, 53, 57, 71, 72 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H2011, HA, U6 - Mental Health Professional H2011-HA, U5-QBHP | Crisis intervention service, per 15 minutes |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Crisis Stabilization Intervention is a scheduled face-to-face treatment activities provided to a beneficiary who has recently experienced a psychiatric or behavioral crisis that are expected to further stabilize, prevent deterioration and serve as an alternative to 24-hour inpatient care. Services are to be congruent with the age, strengths, needed accommodation for any disability and cultural framework of the beneficiary and his/her family. | * Date of service * Start and stop time of actual encounter with beneficiary and possible collateral contacts with caregivers or informed persons * Place of service (When 99 is used, specific location and rationale for location must be included) * Specific persons providing pertinent |
information in relationship to beneficiary * Diagnosis and synopsis of events leading up to crisis situation * Brief mental status and observations * Utilization of previously established psychiatric advance directive or crisis plan as pertinent to current situation OR rationale for crisis intervention activities utilized * Beneficiary's response to the intervention that includes current progress or regression and prognosis * Clear resolution of the cun'ent crisis and/or plans for further services * Development of a cleariy defined crisis plan or revision to existing plan * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS rJifV |
A psychiatric or behavioral crisis is defined as an acute situation in which an individual is experiencing a serious mental illness or emotional disturbance to the point that the beneficiary or others are at risk for imminent harm or in which to prevent significant deterioration of the beneficiary's functioning. This service is a planned intervention that MUST be on the beneficiary's treatment plan to serve as an altemative to 24-hour inpatient care. | 15 Minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 72 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE{S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians -Master's/Doctoral * Advanced Practice Nurse * Physician * Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Regi stered Nurse | 03, 04, 11, 12,14, 33, 49, 50, 53, 57, 71, 72, 99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0035 | Mental health partial hospitalization treatment, less than 24 hours | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Partial Hospitalization is an intensive nonresidential, therapeutic treatment program. It can be used as an alternative to and/or a step-down service from inpatient residential treatment or to stabilize a deteriorating condition and avert hospitalization. The program provides clinical treatment services in a stable environment on a level equal to an inpatient program, but on a less than 24-hour basis. The environment at this level of treatment is highly structured and should maintain a staff-to-patient ratio of 1:5 to ensure necessary therapeutic services and professional monitoring, control, and protection. This service shall include at a minimum intake, individual therapy, group therapy, and psychoeducation. Partial Hospitalization shall be at a minimum (5) five hours per day, of which 90 minutes must be a documented service provided by a Mental Health Professional. If a beneficiary receives other services during the week but also receives Partial Hospitalization, the beneficiary must receive, at a minimum, 20 documented hours of services on no less than (4) four days in that week. | * Start and stop times of actual program participation by beneficiary * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the master treatment plan * Beneficiary's response to the treatment must include current progress or lack of progress toward symptom reduction and attainment of goals * Rationale for continued acute day service, including necessary changes to diagnosis, master treatment plan or medication(s) and plans to transition to less restrictive services * All services provided must be clearly documented in the medical record * Staff signature/credentials | |
NOTES | UNIT | BENEFIT LIMITS |
Partial hospitalization may include drug testing, medical care other than detoxification and other appropriate services depending on the needs of the individual. The medical record must indicate the services provided during Partial Hospitalization. | Per Diem | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 40 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider may not bill for any other services on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Partial Hospitalization must be provided in a facility thiat is certified by the Division of Behavioral Health Services as a Partial Hospitalization provider | 11 ,22,49,52,53 | |
EXAMPLE ACTIVITIES | ||
Care provided to a client who is not ill enough to need admission to facility but w/ho has need of more intensive care in the therapeutic setting than can be provided in the community. This service shall include at a minimum intake, individual and group therapy, and psychosocial education. Partial hospitalization may include drug testing, medical care other than detoxification and other appropriate services depending on the needs of the individual. | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRiptlONilf (&!%:[GREATER THAN] | |
H2019, HK, HN - QBHP Bachelors or RN H2019, HK, HM - QBHP Non-Degreed | H2019: Therapeutic behavioral services, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Behavioral Assistance is a specific outcome oriented intervention provided individually or in a group setting with the child/youth and/or his/her caregiver(s) that will provide the necessary support to attain the goals of the treatment plan. Services involve applying positive behavioral interventions and supports within the community to foster behaviors that are rehabilitative and restorative in nature. The intervention should result in sustainable positive behavioral changes that improve functioning, enhance the quality of life and strengthen skills in a variety of life domains. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with collateral contact * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating treatment * Document how treatment used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS : |
15 minutes | YEARLY IVIAXIMUM OF UNITS THAT MAY BE BILLED (extension | |
of benefits can be requested): 292 | ||
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | A provider can only bill 292 units of H2019, HK, HN or H2019, HK, HM combined per SFY. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2019 with HK, HN modifiers) | 03, 04, 11,12, 13,14, 15.16, 22, 23, 31, 32, 33, 34, 49, 50, 52, 53, 57, 71, 72, 99 | |
EXAMPLE ACTIVITIES | ||
Behavioral Assistance is designed to support youth and their families in meeting behavioral goals in various community settings. The service is targeted for children and adolescents who are at risk of out-of-home placement or who have returned home from residential placement and need flexible wrap-around supports to ensure safety and support community integration. The service is tied to specific treatment goals and is developed in coordination with the youth and their family. Behavioral Assistance aids the family in implementing safety plans and behavioral management plans when youth are at risk for offending behaviors, aggressions, and oppositional defiance. Staff provides supports to youth and their families during periods when behaviors have been typically problematic -such as during morning preparation for school, at bedtime, after school, or other times when there is evidence of a pattern of escalation of problem difficult behaviors. The service may be provided in school classrooms or on school busses for short periods of time to help a youth's transition from | ||
hospitals or residential settings but is not intended behaviors at school. | as a permanent solution to problem difficult | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2017, HK, HN - QBHP Bachelors or RN H2017, HK, HM - QBHP Non-Degreed | Psychosocial rehabilitation services | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
A continuum of care provided to recovering individuals living in the community based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering individual to direct their resources and support systems. Activities include training to assist the person to learn, retain, or improve specific job skills, and to successfully adapt and adjust to a particular work environment. This service includes training and assistance to live in and maintain a | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how treatment used address goals | |
household of their choosing in the community. in addition, transitional services to assist individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration. An an-ay of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery-based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement a beneficiary's master treatment plan. | and objectives from the master treatment plan * Infonnation gained from contact and how it relates to master treatment plan objectives * Impact of infonnation received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentiais/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
staff to Client Ratio -1:15 ratio maximum with the provision that client ratio must be reduced when necessary to accommodate significant issues related to acuity, developmental status and clinical needs. | 60 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 6 units QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 90 units |
APPLICABLE POPULATIONS | SPECIAL BILLING INST | RUCTIONS |
Adult | The following codes cannot be billed on the Same Date of Service: H2015 - Individual Recovery Support, Bachelors H2015 - Individual Recovery Support, Non-Degreed H2015 - Group Recovery Support, Bachelors H2015 - Group Recovery Support, Non-Degreed | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2019 with HK, HN modifiers) | 04, 11, 12, 13, 14, 22, 23, 31, 32, 33, 49, 50, 52, 53,57,71,72,99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0038 H0038, U8 - Telephonic | Self-help/peer services, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Peer Support is a consumer centered service provided by individuals (ages 18 and older) who self-identify as someone who has received or is receiving behavioral health services and thus is able to provide expertise not replicated by professional training. Peer providers are trained and certified peer specialists who self-identify as being in recovery from behavioral health issues. Peer support is a service to work with beneficiaries to provide education, hope, healing, advocacy, self-responsibility, a meaningful role in life, and empowerment to reach fullest potential. Specialists will assist with navigation of multiple systems (housing, supportive employment, supplemental benefits, building/rebuilding natural supports, etc.) which impact beneficiaries' functional ability. Services are provided on an individual or group basis, and in either the beneficiary's home or | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual contact * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how treatment used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of information received/given on the beneficiary's treatment | |
community environment. | * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNlT | BENEFIT LIMITS - |
15 minutes | YEARLY MAXIIVIUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 120 | |
APPLICABLE POPULATION | SPECIAL BILLING INSTRUCTIONS | |
Youtii and Adults | Provider can only bill for 120 units (combined between H0038 and H0038. U8) per SFY | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Certified Peer Support Specialist * Certified Youth Support Specialist | 03, 04,11, 12,13,14, 15,16, 22, 23, 31, 32, 33, 34, 49, 50, 52, 53, 57, 71, 72, 99 | |
EXAMPLE ACTIVITIES | ||
Peer support may include assisting their peers in articulating their goals for recovery, learning and practicing new skills, helping them monitor their progress, assisting them in their treatment, modeling effective coping techniques and self-help strategies based on the specialist's own recovery experience, and supporting them in advocating for themselves to obtain effective services. | ||
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2014 H2014,U8-Telephonic | Skills training and development, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMjENTATION REQUIREMENTS | |
Family Support Partners is a service provided by peer counselors, or Family Support Partners (FSP), who model recovery and resiliency for caregivers of children or youth with behavioral health care needs. Family Support Partners come from legacy families and use their lived experience, training, and skills to help caregivers and their families identify goals and actions that promote recovery and resiliency. A FSP may assist, teach, and model appropriate child-rearing strategies, techniques, and household management skills. This service provides information on child development, age- | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how services used address goals and objectives from the master treatment plan | |
appropriate behavior, parental expectations, and childcare activities. It may also assist the family in securing community resources and developing natural supports. | * Information gained from contact and how it relates to master treatment plan objectives * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
15 minutes | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 120 | |
APPUCABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | Provider can only bill for 120 units (combined between H2014 and H2014, U8) per SFY | |
ALLOWED MODE(S) OF DELIVERY | TJER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Certified Family Support Partner | 03, 04,11,12, 13,14, 15, 16, 22, 23. 31, 32, 33, 34,49,50,52,53,57,71,72,99 | |
EXAMPLE ACTIVITIES | ||
Family Support Partners serve as a resource for families with a child, youth, or adolescent receiving behavioral health services. Family Support Partners help families identify natural supports and community resources, provide leadership and guidance for support groups, and work with families on: individual and family advocacy, social support for assigned families, educational support, systems advocacy, lagging skills development, problem solving technics and self-help skills. | ||
CPT®/HCPCS PROCEDURE CODE | | PROCEDURE CODE DESCRIPTION | |
H0034, TO | Medication training and support | |
SERVICE DESCRIPTION | MINJMUM DOCUMENTATION REQUIREMENTS | |
A specific, time limited one-to-one intervention by a nurse with a beneficiary and/or caregivers, related to their psychopharmological treatment. Individual Pharmaceutical counseling involves providing medication information orally or in written fonn to the beneficiary and/or | * Date of Service * Start and stop times of actual encounter with beneficiary * Place of service | |
caregivers. The service should encompass all the parameters to make the beneficiary and/or family understand the diagnosis prompting the need for the medication and any lifestyle modification required. | * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the master treatment plan * Beneficiary's response to treatment that includes current progress or regression and prognosis * Revisions indicated for the master treatment plan, diagnosis, or medication(s) * Plan for follow-up services, including any crisis plans * Staff signature/credentials/date of signature | |
NOTES | BENEFIT LIMITS ; | |
Encounter | YEARLY IVIAXIMUM OF UNITS THAT IVIAY BE BILLED (extension of benefits can be requested): 12 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth and Adults | Provider can only bill for 12 units (combined between H0034. TD and H0034. HQ, TD) per SFY | |
ALLOWED MODE(S) OF DELIVERY | ||
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Registered Nurse | 03,04,11.12,13,14.15 34, 49, 50, 52, 53, 57, 71 | ,16.22,23,31,32,33, . 72, 99 |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0034, HQ, TD | Medication training and support | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
A specific, time limited intervention provided to a group of beneficiaries and/or caregivers by a nurse, related to their psychophannological treatment Group Phamiaceutical counseling involves providing medication information orally or in written form to the beneficiary and/or caregivers. The service should encompass all the parameters to make the beneficiary and/or family understand the diagnosis prompting the need for the medication and any lifestyle | * Date of Service * Start and stop times of actual encounter with beneficiary * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must | |
modification required. | coincide with the master treatment plan * Beneficiary's response to treatment that includes cun*ent progress or regression and prognosis * Revisions indicated for the master treatment plan, diagnosis, or medication(s) * Plan for follow-up services, including any crisis plans * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Encounter | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth and Adults | Provider can only bill for 12 units (combined between H0034, TD and H0034, HQ, ID) per SFY | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Registered Nurse | 03, 04, 11, 12,13,14, 15,16, 22, 23, 31. 32, 33, 34, 49, 50, 52, 53, 57, 71, 72, 99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0015 | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based upon an individualized treatment plan), including assessment, counseling, crisis intervention, activity therapies or education | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Intensive Outpatient services provide group based, non-residential, intensive, structured interventions consisting primarily of counseling and education to improve symptoms that may significantly interfere with functioning in at least one life domain (e.g., familial, social, occupational, educational, etc.). Services are goal oriented interactions with the individual or in group/family settings. This community based service allows the individual to aoolv skills in | * Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason | |
"real worid" environments. Such treatment may be offered during the day, before or after wori[LESS THAN] or school, in the evening or on a weekend. The services follow a defined set of policies and procedures or clinical protocols. The service also provides a coordinated set of individualized treatment services to persons who are able to function in a school, work, and home environment but are in need of treatment services beyond traditional outpatient programs. Treatment may appropriately be used to transition persons from higher levels of care or may be provided for persons at risk of being admitted to higher levels of care. Intensive outpatient programs provide 9 or more hours per week of skilled treatment, 3-5 times per week in groups of no fewer than three and no more than 12 clients. | * Presenting problem (s), history of presenting problem(s), including duration, intensity, and response(s) to prior treatment * Rationale for service and service used that must coincide with master treatment plan * Beneficiary's response to service that includes current progress or regression and prognosis * Any changes indicated for the master treatment plan, diagnosis, or medication(s) * Mental status/Clinical observations and impressions * Current functioning and strengths in specified life domains * DSI\/I diagnostic impressions to include all axes * Treatment recommendations * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
A prior authorization is required for this service. | Per diem | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 24 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Youth, and Adults | A provider cannot bill any other services on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Intensive Outpatient Substance Abuse Treatment must be provided in a facility that is certified by the Division of Behavioral Health Services as an intensive Outpatient Substance Abuse Treatment provider. | 11.14, ,22.49, 50. 53. 57, 71 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION a v |
H2017, HA, HN - QBHP Bachelors or RN H2017, HA, HM - QBHP Non-Degreed | Psychosocial rehabilitation services, per 15 minutes |
SERVICE DESCRIPTION | MINIMUM DOCUMENT/ mON REQUIREMENTS |
Individual Life Skills Development is a service that provides support and training for transitional aged youth (ages 16 to 21) on a one-on-one basis. This service should be a strength-based, culturally appropriate process that integrates the youth into their community as they develop their recovery plan. This service is designed to assist youth in acquiring the skills needed to support an independent lifestyle and promote a strong sense of self-worth. In addition, it aims to assist youth in setting and achieving goals, leaming independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living. Topics may include: educational or vocational training, employment, resource and medication management, self-care, household maintenance, health, wellness, and nutrition. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter * Place of Service (When 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how services address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of information received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising IVIHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature |
NOTES | UNIT | BENEFIT LIMITS |
15 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 292 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Youth (Age 16-20) | A provider cannot bill any other H2017 code (regardless of service) on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed | 03, 04, 11, 12, 14, 16, 22, 49, 50, 53, 57, 71, 72 | |
* Registered Nurse (Use Code H2017 with HA, HN modifiers) | ||
EXAMPLE ACTIVITIES | ||
General sl[LESS THAN]ills training, family and relationship supports and skill development, parenting support, anger management, basic life skill training, self-help, drug and alcohol management, lifestyle programs, filling out job applications, developing positive interview skills, assisting with passing pemiit test and obtaining a license and/or teaming the mass transit transportation system. | ||
CPTlg)/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION ' | |
H2017, HQ. HN - QBHP Bachelors or RN H2017, HQ, HM - QBHP Non-Degreed | Psychosocial rehabilitation services, per 15 minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Group Life Skills Development is a service that provides support and training for transitional aged youth (ages 16 to 21) in a group setting of up to six (6) beneficiaries with one staff member or up to ten (10) beneficiaries with two staff members. This sen/ice should be a strength-based, culturally appropriate process that integrates the youth into their community as they develop their recovery plan. This service is designed to assist youth in acquiring the skills needed to support an independent lifestyle and promote a strong sense of self-worth. In addition, it aims to assist youth in setting and achieving goals, learning independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living. Topics may include: educational or vocational training, employment, resource and medication management, self-care, household maintenance, health, wellness, and nutrition. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with contact * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating service * Document how services address goals and objectives from the master treatment plan * Infomiation gained from contact and how it relates to master treatment plan objectives * Impact of infomiation received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising l\/IHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES ' | UNIT : -: | BENEFJJ LIMITS |
15 minutes | YEARLY MAXIIVIUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 292 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS |
Youth (Age 16-20) | A provider cannot bill any other H2017 code (regardless of service) on the same date of service. |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face | Rehabilitative |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2017 with HA, HN modifiers) | 03, 04, 11, 14, 16, 22, 49, 50, 53, 57, 71, 72 |
EXAMPLE ACTIVITIES | |
General skills training, family and relationship supports and skill development, parenting support, parenting classes, anger management, basic life skill training, self-help, drug and alcohol management, lifestyle programs,, filling out job applications, developing positive interview skills, assisting with passing permit test and obtaining a driver's license and/or learning the mass transit transportation system . Referrals to Vocational Rehabilitation Services, supportive housing or supportive employment. | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2015, HA, HN - QBHP Bachelors or RN H2015, HA, HM - QBHP Non-Degreed | Comprehensive community support services | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Child and Youth Support Services are clinical, time-limited services for principal caregivers designed to increase a child's positive behaviors and encourage compliance with parents at home; working with teachers/schools to modify classroom environment to increase positive behaviors in the classroom; and increase a child's social skills, including understanding of feelings, conflict management, academic engagement, school readiness, and cooperation with teachers and other school staff. This service is intended to increase parental skill development in managing their child's symptoms of their illness and training the parents in effective interventions and techniques for working with the schools. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with collateral contact * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Information gained from collateral contact and how it relates to master treatment plan objectives | |
Services might include an In-Home Case Aide. An In-Home Case Aide is an intensive, time-limited therapy for youth in the beneficiary's home or, in rare instances, a community based setting. Youth served may be in imminent risk of put-of-home placement or have been recently reintegrated from an out of-home placement. Services may deal with family issues related to the promotion of healthy family interactions, behavior training, and feedback to the family. | * Impact of infomiation received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
60 Minutes | QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 60 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children and Youth | A provider can bill up to 60 units per quarter (Quarters are defined as January-March, April-June, July-September, October-December) prior to an extension of benefits. A provider cannot bill any other H2015 code on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER ,. % '4t* *-''*\fr . --#; V ,}i-" *«' ' -.'- -i'"." | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLAipE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2015 with HA, HN modifiers) | 03, 04,12,16 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2023 | Supportive Employment | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Supportive Employment is designed to lielp beneficiaries acquire and l[LESS THAN]eep meaningful jobs in a competitive job market. Tlie service actively facilitates job acquisition by sending staff to accompany beneficiaries on interviews and providing ongoing support and/or on-the-job training once the beneficiary is employed. This service replaces traditional vocational approaches that provide intermediate work experiences (prevocational work units, transitional employment, or sheltered workshops), which tend to isolate beneficiaries from mainstream society. Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with collateral contact * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Information gained from collateral contact and how it relates to master treatment plan objectives * Impact of infomiation received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
A prior authorization is required for this service. | 60 Minutes | QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 60 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults | A provider can bill up to 60 units per quarter (Quarters are defined as January-March, April-June, July-September, October-December) prior to an extension of benefits. A provider cannot bill any H2017, H2015 code on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | ||
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | ||
* Qualified Beiiavioral Healtli Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse | 04,11.12,16,49,53,57,99 | |
CPTEVHCPCS PROCEDURE CODES | PROCEDURE CODE DESCRIPTION | |
H0043 | Supportive Housing | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUREMENTS | |
Supportive Housing is designed to ensure that beneficiaries have a choice of pemnanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists beneficiaries in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; and facilitates the individual's recovery journey. Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with collateral contact * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Information gained from collateral contact and how it relates to master treatment plan objectives * Impact of infonnation received/given on the beneficiary's treatment * Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
A prior authorization Is required for this service. | 60 Minutes | QUARTERLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 60 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS |
Adults | A provider can bill up to 60 units per quarter (Quarters are defined as January-March, April-June, July-September, October-December) prior to an extension of benefits. A provider cannot bill any H2017, H2015 code on the same date of service. |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face | Rehabilitative |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2015 vi/ith HK, HN modifiers) | 04,11,12,16,49,53,57,99 |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H2017, HN - QBHP Bachelors or RN H2017, HM- QBHP Non-degreed | Comprehensive community support services | |
SERVICE DESCRIPTION | MINIIVIUM DOCUMENTATION REQUIREMENTS | |
Life Skills Development services are designed to assist beneficiaries in acquiring the skills needed to support an independent lifestyle and promote an improved sense of self-worth. Life skills training is designed to assist in setting and achieving goals, teaming independent living skills, demonstrate accountability, and making goal-directed decisions related to independent living (i.e., educational/vocational training, employment, resource and medication management, self-care, household maintenance, health, wellness and nutrition). Service settings may vary depending on individual need and level of community integration, and may include the beneficiary's home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting | * Date of Service * Names and relationship to the beneficiary of all persons involved * Start and stop times of actual encounter with collateral contact * Place of Service (If 99 is used, specific location and rationale for location must be included) * Client diagnosis necessitating intervention * Document how interventions used address goals and objectives from the master treatment plan * Information gained from collateral contact and how it relates to master treatment plan objectives * Impact of infomriation received/given on the beneficiary's treatment * Any changes indicated for the master | |
with the criminal justice system. | treatment plan which must be documented and communicated to the supervising MHP for consideration * Plan for next contact, if any * Staff signature/credentials/date of signature | |
NOTES | BENEFIT LIMITS | |
15 Minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 292 | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Rehabilitative | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Qualified Behavioral Health Provider -Bachelors * Qualified Behavioral Health Provider - Non-Degreed * Registered Nurse (Use Code H2015 with HK, HN modifiers) | 04,11,12,16,49,53,57.99 | |
Eligibility for Intensive Level Services is detennined by the Intensive Level Services standardized independent Assessment.
Prior to reimbursement for Therapeutic Communities or Planned Respite in Intensive Level Services, a beneficiary must be eligible for Rehabilitative Level Services as determined by the standardized Independent Assessment. The beneficiary must then also be determined by an Intensive Level Services Independent Assessment to be eligible for Therapeutic Communities.
Eligibility for entry into a residential setting requires adherence to appropriate Medicaid rules regarding that residential setting. Eligibility for Therapeutic Communities requires that an Individualized Treatment Plan be developed for the beneficiary. The beneficiary will be supported in Treatment Plan development by a care coordinator and allowed the ability to choose who they want to participate in the development of the Individualized Treatment Plan.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0019, HQ-Level 1 H0019, HQ, HK-Level2 | Behavioral health; long-term residential (nonmedical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem. | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Therapeutic Communities are highly structured residential environments or continuums of care in which the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability. Services address the broad range of needs identified by the person served. Therapeutic Communities employs community-imposed consequences and earned privileges as part of the recovery and growth process. In addition to daily seminars, group counseling, and individual activities, the persons served are assigned responsibilities within the therapeutic community setting. Participants and staff members act as facilitators, emphasizing personal responsibility for one's own life and self-improvement. The service emphasizes the integration of an individual within his or her community, and progress is measured within the context of that community's expectation. | * Date of Service * Names and relationship to the beneficiary of all persons involved * Place of Service * Document how interventions used address goals and objectives from the master treatment plan * Information gained from contact and how it relates to master treatment plan objectives * Impact of infonnation received/given on the beneficiary's treatment * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Therapeutic Communities Level will be determined by the following: * Functionality based upon the Independent Assessment Score * Outpatient Treatment History and Response * Medication * Compliance with Medication/Treatment Eligibility for this service is determined by the Intensive Level Services standardized Independent Assessment. Prior to reimbursement for Therapeutic Communities in Intensive Level Services, a beneficiary must be eligible for Rehabilitative Level Services as determined by the standardized Independent Assessment. The beneficiary must then also be determined by an Intensive Level Services Independent Assessment to be eligible for Therapeutic Communities. | Per Diem | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): H0019, HQ-180 H0019, HQ, HK-185 |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS |
Adults | A provider cannot bill any other services on the same date of service. |
PROGRAM SERVICE CATEGORY | |
Intensive | |
ALLOWED MODE(S) OF DELIVERY | TIER |
Face-to-face | N/A |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE |
Therapeutic Communities must be provided in a facility that Is certified by the Division of Behavioral Health Services as a Therapeutic Communities provider | 14.21,51.55 |
CPT(§)/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H0045 | Respite care services, per diem |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Planned Respite provides temporary direct care and supervision for a beneficiary in the beneficiary's community that is not facility-based. The primary purpose is relief to the principal caregiver of an individual with a behavioral health need. Respite services de-escalate stressful situations and provide a therapeutic outlet. Services should be scheduled and reflected in the wraparound or treatment plan. Planned Respite can only be provided by a provider who is certified by the Division of Behavioral Health Services as a Planned Respite provider. | |
NOTES | EXAMPLE ACTIVITIES |
Eligibility for this service is determined by the Intensive Level Services standardized Independent Assessment. Prior to reimbursement for Planned Respite in Intensive Level Services, a beneficiary must be eligible for Rehabilitative Level Services as determined by the standardized Independent Assessment. The beneficiary must then also be determined by an Intensive Level Services Independent Assessment to be eligible for Planned Respite. |
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Children and Youth | Per Diem | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 8 |
PROGRAM SERVICE CATEGORY | ||
Intensive | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Planned Respite must be provided in a facility that is certified by the Division of Behavioral Health Services as a Planned Respite provider. | 04.12,16,49,53,57,99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION |
H2011,HA | Crisis intervention service, per 15 minutes |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS |
Crisis Intervention is unscheduled, immediate, short-term treatment activities provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services are designed to stabilize the person in crisis, prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. (These activities include evaluating a Medicaid-eligible beneficiary to determine if the need for crisis services is present.) | * Date of service * Start and stop time of actual encounter with beneficiary and possible collateral contacts with caregivers or informed persons * Place of service * Specific persons providing pertinent information in relationship to beneficiary * Diagnosis and synopsis of events leading up to crisis situation * Brief mental status and observations * Utilization of previously established psychiatric advance directive or crisis plan as pertinent to current situation OR rationale for crisis intervention activities utilized * Beneficiary's response to the intervention that includes current progress or regression and prognosis * Clear resolution of the cuaent crisis and/or |
plans for further services * Development of a cleariy defined crisis plan or revision to existing plan * Staff signature/credentials/date of signature(s) | ||
NOTES | UNIT | BENEFIT LIMITS |
A psychiatric or behavioral crisis is defined as an acute situation in which an individual is experiencing a serious mental illness or emotional disturbance to the point that the beneficiary or others are at risk for imminent harni or in which to prevent significant deterioration of the beneficiary's functioning. This service can be provided to beneficiaries that have not been previously assessed or have not previously received behavioral health services. The provider of this service MUST complete a Mental Health Diagnosis (90791) within 7 days of provision of this service if provided to a beneficiary who is not currently a client. If the beneficiary cannot be contacted or does not return for a Mental l-lealth Diagnosis appointment, attempts to contact the beneficiary must be placed in the beneficiary's medical record. If the beneficiary needs more time to be stabilized, this must be noted in the beneficiary's medical record and the Division of Medical Services Quality Improvement Organization (QIO) must be notified. | 15 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 72 |
APPLICABLE POPULATONS | SPECIAL BlLLiNG INSTRUCTlONS | |
Children, Youth, and Adults | ||
ALLOWED MODE (S) DELIVERY | TIER | |
Face-to-face | Crisis | |
ALLOWABLE PERFORMING FROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral (must be employed by Behavioral Health Agency) * Non-independently Licensed Clinicians -Master's/Doctoral (must be employed by Behavioral Health Agency) * Advanced Practice Nurse (must be employed by Behavioral Health Agency) * Physician (must be employed by Behavioral Health Agency) | 03, 04,11,12,14, 33, 49, 50, 53, 57, 71, 72 ,99 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
N/A | N/A | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Acute Psychiatric Hospitalization is indicated when a lesser restrictive environment is not adequate to ensure the safety of the beneficiary and others. | Refer to Hospital/Critical Access Hospital/End-Stage Renal Disease Manual for adults and Inpatient Psychiatric Services for Under Age 21 Manual for Under Age 21 | |
NOTES | EXAMPLE ACTIVITIES | |
Refer to Hospital/Critical Access Hospital/End-Stage Renal Disease Manual for adults and Inpatient Psychiatric Services for Under Age 21 Manual for Under Age 21 | ||
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Children, Youth, and Adults | Per Diem | Refer to Hospital/Critical Access Hospital/End-Stage Renal Disease Manual for adults and Inpatient Psychiatric Services for Under Age 21 Manual for Under Age 21 |
PROGRAM SERVICE CATEGORY | ||
Crisis Service | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
N/A | 21,51 | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
H0018 | Behavioral Health; short-term residential | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Acute Crisis Units provide brief (96 hours or less) crisis treatment services to persons over the age of 18 who are experiencing a psychiatry- and/or substance abuse-related crisis and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and step-down services in a safe environment with psychiatry and/or substance abuse services on-site at all times as well as on-call psychiatry available 24 hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occuning treatment; and initiate referral mechanisms for independent assessment and care planning as needed. | ||
NOTES | EXAMPLE ACTIVITIES | |
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Youth and Adults | Per Diem | * 96 hours or less per encounter * 1 encounter per month * 6 encounters per SPY |
PROGRAM SERVICE CATEGORY | ||
Crisis Services | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
N/A | 21,51,55,56 | |
CPT®/HCPCS PROCEDURE Code | PROCEDURE CODE DESCIRIPTION | |
H0014 | Alcohol and/or drug services; detoxification | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term and may be provided in a crisis unit, inpatient, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment. Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment. | ||
NOTES | EXAMPLE ACTIVITIES | |
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Youth and Adults | N/A | * 1 encounter per month * 6 encounters per SFY |
PROGRAM SERVICE CATEGORY | ||
Crisis Services | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
N/A | 21,55 | |
The Arkansas licensed mental health professional may provide certain treatment services from a remote site to the Medicaid-eligible beneficiary who is located in a mental health clinic setting. See Section 257.100 for billing instructions.
The following services may be provided via telemedicine by an Arkansas licensed mental health professional to Medicaid-eligible beneficiaries under age 21 and Medicaid-eligible beneficiaries age 21 and over; bill with POS 99:
National Code | Required Modifier | Service Title |
90832 90834 90837 | U7 U7 U7 | Individual Behavioral Health Counseling -Telemedicine |
H2027 | U7 | Psychoeducation - Telemedicine |
90792 | U7 | Psychiatric Assessment - Physician, APN -Telemedicine |
99212 99213 99214 | U7, UB U7, UB U7, UB | Pharmacologic Management - Physician, Telemedicine |
99212 99213 99214 | U7, SA U7,SA U7, SA | Phamiacologic Management - APN, Telemedicine |
90887 | U7 | Interpretation of Diagnosis |
The following services may be provided via telemedicine by a mental health professional to Medicaid-eligible beneficiaries age 21 and over; bill with POS 99:
National Code | Required IVIodifier | Service Titie |
90791 | U7 | Mental Health Diagnosis |
Information
The following Outpatient Behavioral Health Services procedure codes are payable to an Outpatient Behavioral Health provider for services provided to residents of nursing homes who are l\4edicaid eligible when prescribed according to policy guidelines detailed in this manual:
National Code | Required Modifier | Procedure Code Description |
90791 | Mental Health Diagnosis | |
S0220 | Treatment Plan (payable only for beneficiaries eligible to receive Rehabilitative Level Services or Intensive Level Services) | |
90887 | Interpretation of Diagnosis | |
90832 90834 90837 | Individual Behavioral Health Counseling |
Services provided to nursing home residents may be provided on or off site from the Outpatient Behavioral Health Services provider. The services may be provided in the long-term care (LTC) facility, if necessary.
Electronic and paper claims now require the same national place of service codes.
Place of Service | PCS Codes |
Outpatient Hospital | 22 |
Office (Outpatient Behavioral Health Provider Facility Service Site) | 11 |
Patient's Home | 12 |
Nursing Facility | 32 |
Skilled Nursing Facility | 31 |
School (Including Licensed Child Care Facility) | 03 |
Homeless Shelter | 04 |
Assisted Living Facility (Including Residential Care Facility) | 13 |
Group Home | 14 |
ICF/IDD | 54 |
Other Locations | 99 |
Outpatient Behavioral Health Services Clinic (Telemedicine) | 99 |
Emergency Services in ER | 23 |
Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore, claims submitted on paper are paid once a month. The only claims exempt from this process are those that require attachments or manual pricing.
To bill for Outpatient Behavioral Health services, use the CMS-1500 fonn. The numbered items correspond to numbered fields on the claim fonn. View a CMS-1500 sample form.
When completing the CMS-1500, accuracy, completeness and clarity are important. Claims cannot be processed if applicable infomriation is not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be fonvarded to Hewlett Packard Enterprise. View or print Hewlett Packard Enterprise Claims contact information.
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
Field Name and Number | Instructions for Completion |
1. (type of coverage) | Not required. |
la. INSURED'S I.D. NUMBER (For Program in Item 1) | Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number. |
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) | Beneficiary's or participant's last name and first name. |
3. PATIENT'S BIRTH DATE | Beneficiary's or participant's date of birth as given on the individual's IVIedicaid or ARKids First-A or ARKids First-B identification card. Fonnat: MM/DDAT. |
SEX | Check M for male or F for female. |
4. INSURED'S NAME (Last Name, First Name, Middle Initial) | Required if insurance affects this claim. Insured's last name, first name, and middle initial. |
5. PATIENT'S ADDRESS (No., Street) | Optional. Beneficiary's or participant's complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary or participant resides. |
STATE | Two-letter postal code for the state in which the beneficiary or participant resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone |
6. PATIENT RELATIONSHIP TO INSURED | If insurance affects this claim, check the box indicating the patient's relationship to the insured. |
7. INSURED'S ADDRESS (No.. Street) | Required if insured's address is different from the patient's address. |
CITY | |
STATE | |
ZIP CODE | |
TELEPHONE (Include Area Code) | |
8. PATIENT STATUS | Not required. |
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) | If patient has other insurance coverage as indicated in Field 11d, the other insured's last name, first name, and middle initial. |
a. OTHER INSURED'S POLICY OR GROUP NUMBER | Policy and/or group number of the insured individual. |
b. OTHER INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
c. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9 a-d are required. Name of the insured individual's employer and/or school. |
d. INSURANCE PLAN NAME OR PROGRAM NAME | Name of the insurance company. |
10. IS PATIENT'S CONDITION RELATED TO: | |
a. EMPLOYMENT? (Current or Previous) | Check YES or NO. |
b. AUTO ACCIDENT? | Required when an auto accident is related to the services. Check YES or NO. |
PLACE (State) | If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. |
c. OTHER ACCIDENT? | Required when an accident other than automobile is related to the sen/ices. Check YES or NO. |
10d. RESERVED FOR LOCAL USE | Not used. |
11. INSURED'S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
a. INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
b. EMPLOYER'S NAME OR SCHOOL NAME | Not required. |
c. INSURANCE PLAN NAME OR PROGRAM NAME | Not required. |
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d. |
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) | Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. |
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE | Not required. |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. (blank) 17b. NPI | Primary Care Physician (PCP) referral or PCMH sign-off is required for Outpatient Behavioral Health Services for all beneficiaries after 3 Counseling Level Services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. The 9-digit Arkansas Medicaid provider ID number of the referring physician. Not required. |
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Fomnat: MMlDOrYY. |
19. RESERVED FOR LOCAL USE | Not applicable to Outpatient Behavioral Health Services. |
20. OUTSIDE LAB? $ CHARGES | Not required. Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. |
Use "9" for ICD-9-CM. | |
Use"0"forlCD-10-CM. | |
Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. | |
Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. | |
22. MEDICAID RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Reserved for future use. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24A. DATE(S) OF SERVICE | The "from" and "to" dates of sen/ice for each billed service. Fomriat: MM/DDA. |
1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. | |
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. | |
B. PLACE OF SERVICE | Two-digit national standard place of service code. See Section 252.200 for codes. |
C. EMG | Enter "Y" for "Yes" or leave blank if "No". EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the con-ect OPT or HCPCS procedure codes from Sections 252.100 through 252.150. |
MODIFIER | Use applicable modifier. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The "Diagnosis Pointer" is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other beneficiary of the provider's services. |
G. DAYS OR UNITS | The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.. |
H. EPSDT/Family Plan | Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. |
1. ID QUAL | Not required. |
J. RENDERING PROVIDER ID# | The 9-digit Arkansas Medicaid provider ID number of the individual who fumished the services billed for in the detail. |
NPI | Not required. |
25. FEDERAL TAX I.D. NUMBER | Not required. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. PATIENT'S ACCOUNT NO. | Optional entry that may be used for accounting |
purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN." | |
27. ACCEPT ASSIGNMENT? | Not required. Assignment is automatically accepted |
by the provider when billing Medicaid. | |
28. TOTAL CHARGE | Total of Column 24F-the sum all charges on the |
claim. | |
29. AMOUNT PAID | Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not include In this total the automatically deducted Medicaid or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS | The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
32. SERVICE FACILITY LOCATION INFORMATION | Enter the name and street, city, state, and zip code of tfie facility where services were performed. |
a. (blank) | Not required. - |
b. Service Site Medicaid ID number | Enter the 9-digit Arkansas Medicaid provider ID number of the service site. |
33. BILLING PROVIDER INFO & PH# | Billing provider's name and complete address. Telephone number is requested but not required. |
a. (blanl[LESS THAN]) | Not required. |
b. (blank) | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
Outpatient Behavioral Health Services Medicaid providers who provide covered telemedicine services must comply with the definitions and coding requirements outlined below when billing Medicaid.
Telemedicine Site Definitions
Local Site: The local site is the patient's location.
Remote Site: The remote site is the location of the Arkansas licensed mental health professional performing a telemedicine service for the beneficiary at the local site.
Telemedicine Place of Service Codes
Paper Claims Code = H, Electronic Claims Code = 99 Outpatient Behavioral Health Providers Clinic (Telemedicine)
Certain Outpatient Behavioral Health Services are covered by Arkansas Medicaid for an individual whose primary diagnosis is substance abuse. Those services are listed below:
National Code | Required Modifier | Procedure Code Description |
90832 90834 90837 | HF HF HF | I ndividual Behavioral Health Counseling - Substance Abuse |
90853 | HF | Group Behavioral Health Counseling - Substance Abuse |
90847 | HF | Marital/Family Behavioral Health Counseling with Beneficiary |
Present - Substance Abuse | ||
90846 | HF | Marital/Family Behavioral Health Counseling without Beneficiary Present - Substance Abuse |
90849 | HF | Multi-Family Behavioral Health Counseling - Substance Abuse |
90791 90791 | U7 | Mental Health Diagnosis |
90887 90887 | U7 | I nterpretation of Diagnosis |
H0001 | Substance Abuse Assessment | |
H0015 | intensive Outpatient Substance Abuse Treatment |
For an Outpatient Behavioral Health Services provider delivering an Outpatient Behavioral Health Services service, the primary diagnosis is the DSM mental health disorder that is the primary focus of the mental health treatment service being delivered.
For persons being treated by an Outpatient Behavioral Health Services provider for a mental health disorder who also have a co-occurring substance use disorder(s), this (these) substance use disorder(s) is (are) listed as a secondary diagnosis. Outpatient Behavioral Health Services providers that are certified to provider Substance Abuse services may also provide substance abuse treatment services to their behavioral health clients. I n the provision of Outpatient Behavioral Health Services mental health services, the substance use disorder is appropriately focused on with the client in temns of its impact on and relationship to the primary mental health disorder. All Outpatient Behavioral Health Services must be focused toward and address the behavioral health needs of the client.
Notice:
The current Arkansas State Plan may be viewed at the following link: https://www.medicaid.state.ar.us/General/units/ppd.aspx
State Plan Amendment pages (SPAs) included in this packet are proposed changes to the Arkansas State Plan until they receive final approval from the Centers for Medicare and Medicaid Services (CMS). I nterested parties are encouraged to visit the included link for the most up-to-date information available.
This notice is provided for information only and is subject to change.
016.06.16 Ark. Code R. 024