016-29-22 Ark. Code R. § 16
Medicaid (Medical Assistance) is designed to assist eligible Medicaid clients in obtaining medical care within the guidelines specified in Section I of this manual. Counseling Services are covered by Medicaid when provided to eligible Medicaid clients by enrolled providers.
Counseling Services may be provided to eligible Medicaid clients at all provider certified/enrolled sites. Allowable places of service are found in the service definitions located in Section 252 and Section 255 of this manual.
All behavioral health providers approved to receive Medicaid reimbursement for services to Medicaid clients must meet specific qualifications.
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.
DMS 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:
Counseling Services are limited to enrolled providers as indicated in 202.000 who offer core counseling services for the treatment of behavioral disorders.
An Counseling Services providers must establish an emergency response plan. Each provider must have 24-hour emergency response capability to meet the emergency treatment needs of the Counseling Services clients served by the provider. The provider must implement and maintain a written policy reflecting the specific coverage plan to meet this requirement. A machine recorded voice mail message to call 911 or report to the nearest emergency room in and of itself is not sufficient to meet the requirement.
All Counseling Services providers must demonstrate the capacity to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.
Each Counseling Services provider must ensure that they employ staff which are able and available to provide appropriate and adequate services offered by the provider. Counseling Services staff members must provide services only within the scope of their individual licensure.
The following chart lists the terminology 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 |
Independently Licensed Clinicians - Master's/Doctoral | Licensed Certified Social Worker (LCSW) Licensed Marital and Family Therapist (LMFT) Licensed Psychologist (LP) Licensed Psychological Examiner - Independent (LPEI) Licensed Professional Counselor (LPC) | Yes, must be licensed through the relevant licensing board to provide services | Not Required |
Non-independently Licensed Clinicians - Master's/Doctoral | Licensed Master Social Worker (LMSW) Licensed Associate Marital and Family Therapist (LAMFT) Licensed Associate Counselor (LAC) Licensed Psychological Examiner (LPE) Provisionally Licensed Psychologist (PLP) Provisionally Licensed Master Social Worker (PLMSW) | Yes, must be licensed through the relevant licensing board to provide services and be employed or contracted by a certified Behavioral Health Agency, Community Support System Agency, or certified by the Dept. of Education as a school based mental health provider | Required |
Licensed Alcoholism and Drug Abuse Counselor Master's | Licensed Alcoholism and Drug Abuse Counselor (LADAC) Master's Doctoral | Yes, must be licensed through the relevant licensing board to provide services | |
Advanced Practice Nurse (APN) | Adult Psychiatric Mental Health Clinical Nurse Specialist Child Psychiatric | Must be employed or contracted by a certified Behavioral Health Agency, or Community Support System Agency | Collaborative Agreement with Physician Required |
Mental Health Clinical Nurse Specialist Adult Psychiatric Mental Health APN Family Psychiatric Mental Health APN | |||
Physician | Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) | Must be employed or contracted by a certified Behavioral Health Agency, or Community Support System Agency | 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 a Counseling Services provider files a claim with Arkansas Medicaid, the staff member who actually performed the service must be identified on the claim as the rendering provider. This action is taken in compliance with the federal Improper Payments Information Act of 2002 (IPIA), Public Law 107-300, and the resulting Payment Error Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).
As illustrated in the chart in § 211.200, certain Counseling Services billing providers are required to be certified by the Division of Provider Services and Quality Assurance. The certification requirements for performing providers are located on the DPSQA website.
The Counseling 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 Counseling Services are not provided in buildings, a safe and appropriate setting must be provided.
The Counseling Services provider may not refuse services to a Medicaid-eligible client who meets the requirements for Counseling Services as outlined in this manual. If a provider does not possess the services or program to adequately treat the client's behavioral health needs, the provider must communicate this with the Primary Care Physician (PCP) or Patient-Centered Medical Home (PCMH) for clients receiving Counseling Services so that appropriate provisions can be made.
The Counseling Services Program provides treatment and services which are provided by a certified Behavioral Health Services provider to Medicaid-eligible clients that have a Behavioral Health diagnosis as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-5 and subsequent revisions).
Eligibility for services depends on the needs of the client. Counseling services and Crisis Services can be provided to any client as long as the services are medically necessary
COUNSELING SERVICES
Time-limited behavioral health services provided by qualified licensed practitioners in an allowable 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, child advocacy center, home, shelter, group home, and/or school.
The intake assessment, either the Mental Health Diagnosis, Substance Abuse Assessment, or Psychiatric Assessment, must be completed prior to the provision of counseling services in the Counseling Services program manual. This intake will assist providers in determining services needed and desired outcomes for the client. The intake must be completed by a behavioral health professional qualified by licensure and experienced in the diagnosis and treatment of behavioral health disorders.
Prior to continuing provision of counseling services, the provider must document medical necessity of Counseling Services. The documentation of medical necessity is a written intake assessment that evaluates the client's mental condition, and, based on the client's diagnosis, determines whether treatment in the Counseling Services Program is appropriate. This documentation must be made part of the client's medical record.
View or print the procedure codes for counseling services.
Please refer to the Independent Assessment Manual or the PASSE Manual for Independent Assessment Referral Process.
Counseling Services providers provide counseling services by qualified licensed practitioners in an outpatient-based setting for the purpose of assessing and treating behavioral health conditions.
Counseling Services providers may provide dyadic treatment of clients age zero through forty-seven (0-47) months and the parent/caregiver of the eligible client. 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 performing providers of parent/caregiver and child Counseling Services MUST be certified by DAABHS to provide those services.
Providers will diagnose children through the age of forty-seven (47) months based on the most current version of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Providers will then crosswalk the diagnosis to a DMS diagnosis.
Specified Z and T codes and conditions that may be the focus of clinical attention according to DSM 5 or subsequent editions will be allowable for this population.
Effective for dates of service on and after September 1, 2020, Medication Assisted Treatment for Opioid Use Disorders is available to all qualifying Medicaid clients when provided by providers who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment for billing purposes. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.
Certain Counseling Services are covered by Arkansas Medicaid for an individual whose primary diagnosis is substance abuse. Licensed Practitioners may provide Substance Abuse Service within the scope of their practice. Individuals solely licensed as Licensed Alcoholism and Drug Abuse Counselors (LADAC) may only provide services to individuals with a primary substance use diagnosis. Behavioral Health Agency and Community Support System Providers Intensive and Enhanced sites must be licensed by the Divisions of Provider Services and Quality Assurance in order to provide Substance Abuse Services.
Each client that receives counseling services in the Counseling Services program can receive a limited amount of counseling 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 client's medical record.
A client can receive ten (10) counseling services before a PCP/PCMH referral is necessary. Crisis Intervention (Section 255.001) does not count toward the ten (10) counseling services. The PCP/PCMH referral must be kept in the client's medical record.
The Patient Centered Medical Home (PCMH) will be responsible for coordinating care with a client's PCP or physician for counseling services. Medical responsibility for clients receiving counseling services shall be vested in a physician licensed in Arkansas.
The PCP referral or PCMH authorization for counseling 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 client'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.
For services that are not reimbursed on a per diem or per encounter rate, Medicaid has established daily benefit limits for all services. Clients will be limited to a maximum of eight (8) hours per twenty-four (24) hour day of Counseling Services. Clients 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).
See Section I for Telemedicine policy and Section III for Telemedicine billing protocol
Services not covered under the Counseling Services Program include, but are not limited to:
Counseling services providers are responsible for communication with the client's primary care physician in order to ensure psychiatric and medical conditions are monitored and addressed by appropriate physician oversight and that medication evaluation and prescription services are available to individuals requiring pharmacological management.
Diagnosis and clinical impression are required in the terminology of ICD.
All Counseling 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:
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 thirty (30) day period.
The approval by the PCP or PCMH will serve as the prescription for counseling services in the Counseling 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.
Prescriptions shall be based on consideration of an evaluation of the enrolled client. The prescription for the services and subsequent renewals must be documented in the client's medical record.
The Utilization Review Section of the Arkansas Division of Medical Services has the responsibility for assuring quality medical care for its clients, along with protecting the integrity of both state and federal funds supporting the Medical Assistance Program.
The Division of Medical Services (DMS) of the Arkansas Department of Human Services has contracted with a Quality Improvement Organization (QIO) or QIO-like organization to perform retrospective (post payment) reviews of counseling services provided by Counseling Services 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.
The purpose of the review is to:
On a calendar quarterly basis, the contractor will select a statistically valid random sample from an electronic data set of all Counseling Services clients whose dates of service occurred during the three (3) -month selection period. If a client was selected in any of the three (3) calendar quarters prior to the current selection period, then they will be excluded from the sample and an alternate client 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 clients selected for the random sample along with instructions for submitting the medical record. The request will include the client'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 information 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 electronic medium. View or print current contractor contact information. Records will not be accepted via email.
The record will be reviewed using a review tool based upon the promulgated Medicaid Counseling 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 therapy (LP, LCSW, LMSW, LPE, LPE-I, LPC, LAC, LMFT, LAMFT, 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 client. Each denial letter contains a rationale for the denial that is record specific and each party is provided information 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 services, 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 information that supports the paid claim. If the information submitted does not support the paid claim, the reviewer will send a denial letter to the provider and the client. Each denial letter contains a rationale for the denial that is record-specific and each party is provided information 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 client 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 (30) days of the date on the letter explaining the denial of services.
Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas 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 current contractor has denied because the records submitted do not support the claim of medical necessity.
Arkansas Medicaid will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid client name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.
The Division of Medical Services contracts with third-party vendor to complete the prior authorization and extension of benefit processes.
Prior Authorization is required for certain Counseling Services provided to Medicaid-eligible clients under the age of four (4).
Information related to clinical management guidelines and authorization request processes is available at current contractor's website.
View or print procedure codes that require prior authorization for Counseling Services
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 client exceeds eight (8) 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 clients. View or print current contractor contact information. Information related to clinical management guidelines and authorization request processes is available at 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 client 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 client is eligible for Arkansas Medicaid prior to rendering services.
Fifteen (15) -Minute Units, unless otherwise stated
Counseling Services must be billed on a per unit basis as indicated in the service definition, as reflected in a daily total, per client, per service.
Time spent providing services for a single client may be accumulated during a single, 24-hour calendar day. Providers may accumulatively bill for a single date of service, per client, per counseling service. Providers are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Counseling 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 determines the number of units allowed.
15 Minute Units | Timeframe |
One (1) unit = | 8 - 24 minutes |
Two (2) units = | 25 - 39 minutes |
Three (3) units = | 40 - 49 minutes |
Four (4) units = | 50 - 60 minutes |
60 minute Units | Timeframe |
One (1) unit = | 50-60 minutes |
Two (2) units = | 110-120 minutes |
Three (3) units = | 170-180 minutes |
Four (4) units = | 230-240 minutes |
Five (5) units = | 290-300 minutes |
Six (6) units = | 350-360 minutes |
Seven (7) units= | 410-420 minutes |
Eight (8) units= | 470-480 minutes |
In a single claim transaction, a provider may bill only for service time accumulated within a single day for a single client. There is no "carryover" of time from one day to another or from one client to another.
Documentation in the client'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 client or provider of the service.
Arkansas Medicaid provides fee schedules on the DMS website. 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 twenty (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 twenty (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 Services 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 fifteen (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 fifteen (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 Services.
Counseling Services providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid clients. Each claim may contain charges for only one (1) client. View a CMS-1500 sample form.
Section III of this manual contains information about available options for electronic claim submission.
Covered counseling services are outpatient services. Specific Counseling Services are available to inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine, and to nursing home residents. Counseling Services are billed on a per unit or per encounter basis as listed. All services must be provided by at least the minimum staff within the licensed scope of practice to provide the service.
The allowable services differ by the age of the client and are addressed in the Applicable Populations section of the service definitions in this manual.
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Psychotherapy, 30 min Psychotherapy, 45 min 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. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse condition, 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 client * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale and description of the treatment used that must coincide with the most recent intake assessment * Client's response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the diagnosis, or medication concerns * Plan for next individual therapy session, including any homework assignments and/or advanced psychiatric directive or crisis plans * 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 intake assessment. Services must be consistent with established behavioral healthcare standards. Individual Psychotherapy is not permitted with clients who do not have the cognitive ability to benefit from the service. This service is not for clients under four (4) years of age except in documented exceptional cases. This service will require a Prior Authorization for clients four (4) years of age. | 30 minutes 45 minutes 60 minutes View or print the procedure codes for counseling services. | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) encounter between all three (3) codes. YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) encounters between all three (3) codes |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults Residents of Long-Term Care Facilities | A provider may only bill one (1) Individual Behavioral Health Counseling Code per day per client. A provider cannot bill any other Individual Behavioral Health Counseling Code on the same date of service for the same client. There are twelve (12) total individual counseling encounters allowed per year regardless of code billed for Individual Behavioral Health Counseling, unless prior to an extension of benefits approved by the Quality Improvement Organization contracted with Arkansas Medicaid. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE (POS) | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurses * Physicians * Providers of services for clients under four (4) years of age must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Group psychotherapy (other than of a multiplefamily group) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Group Behavioral Health Counseling is a face-to-face treatment provided to a group of clients. Services leverage the emotional interactions of the group's members to assist in each client's treatment process, support their rehabilitation effort, and to minimize relapse. Services pertain to a client's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the client, client-centered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. | * Date of Service * Start and stop times of actual group encounter that includes identified client * Place of service * Number of participants * Diagnosis and pertinent interval history * Focus of group * Brief mental status and observations * Rationale for group counseling must coincide with the most recent intake assessment * Client's response to the group counseling that includes current progress or regression and prognosis * Any revisions indicated for diagnosis, or medication concerns * Plan for next group session, including any homework assignments or crisis plans, or both * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
This does NOT include psychosocial groups. Clients eligible for Group Behavioral Health Counseling 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 clients eighteen (18) years of age and over, the minimum number that must be served in a specified group is two (2). The maximum that may be served in a specified group is twelve (12). For groups of clients under eighteen (18) years of age, the minimum number that must be served in a specified group is two (2). The maximum that may be served in a specified group is ten (10). A client must be at least four (4) years of age to receive group therapy. Group treatment must be age and developmentally appropriate, (i.e., sixteen (16) year-olds and four (4) year-olds must not be treated in the same group). Providers may bill for services only at times during which clients participate in group activities. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) encounters |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one (1) Group Behavioral Health Counseling encounter per day. There are twelve (12) total group behavioral health counseling encounters allowed per year, unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, eighteen (18) years of age and above) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurses * Physicians | 02 (Telemedicine), 03 (School), 10 (Telehealth Provided in Client's Home), 11 (Office), 49 (Independent Clinic), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substances Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Family psychotherapy (conjoint psychotherapy) (with patient present) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Marital/Family Behavioral Health Counseling with Client Present is a face-to-face treatment provided to one (1) or more family members in the presence of a client. 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 client's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the client, client-centered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children who are from zero through forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment must be prior authorized. Dyadic Infant/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 nationally recognized evidence based practice. Practices include, but are not limited to, Child-Parent Psychotherapy (CPP) and Parent Child Interaction Therapy (PCIT). **Dyadic treatment by telemedicine must continue to assure adherence to the evidence-based protocol for the treatment being provided, i.e. PCIT would require a video component sufficient for the provider to be able to see both the parent and child, have a communication device (ear phones, ear buds, etc.) to enable the provider to communicate directly with the parent only while providing directives related to the parent/child interaction. | * Date of Service * Start and stop times of actual encounter with client and spouse/family * Place of service * Participants present and relationship to client * Diagnosis and pertinent interval history * Brief mental status of client and observations of client with spouse/family * Rationale, and description of treatment used must coincide with the most recent intake assessment and improve the impact the client's condition has on the spouse/family or improve marital/family interactions between the client and the spouse/family, or both * Client and spouse/family's response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * 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 documentation in the Mental Health Diagnosis. Only one (1) client per family, per therapy session, may be billed. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) encounters |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one (1) Marital/Family Behavioral Health Counseling with (or without) Patient encounter per day. There are twelve (12) total Marital/Family Behavioral Health Counseling with Client Present encounters allowed, per year, unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. The following services cannot be billed on the Same Date of Service: Multi-Family Behavioral Health Counseling Marital/Family Behavioral Health Counseling without Client Present Psychoeducation View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services * Independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Family psychotherapy (without the patient present) | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Marital/Family Behavioral Health Counseling without Client Present is a face-to-face treatment provided to one (1) or more family members outside the presence of a client. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support, and develop alternative strategies to address familial issues, problems, and needs. Services pertain to a client's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the client or family member(s), clientcentered, and strength-based; with emphasis on needs as identified by the client and family and provided with cultural competence. | * Date of Service * Start and stop times of actual encounter with spouse/family * Place of service * Participants present and relationship to client * Diagnosis and pertinent interval history * Brief observations with spouse/family * Rationale, and description of treatment used must coincide with the most recent intake assessment and improve the impact the client's condition has on the spouse/family, or improve marital/family interactions between the client and the spouse/family, or both * Client and spouse/family's response to treatment that includes current progress or regression and prognosis * Rationale for excluding the identified client * Any revisions indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * 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 Mental Health Diagnosis. Only one (1) client per family per therapy session may be billed. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) encounters |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill one (1) Marital/Family Behavioral Health Counseling with (or without) Client encounter per day. The following codes cannot be billed on the Same Date of Service: Multi-Family Behavioral Health Counseling Marital/Family Behavioral Health Counseling with Client Present Psychoeducation Infant mental health providers may provide up to (four) 4 encounters of family therapy with or without beneficiary present in a single date of service. View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Psychoeducational service; per fifteen (15) minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Psychoeducation provides clients and their families with pertinent information 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 (2) formats: multifamily group and/or single-family group. Due to the group format, clients 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 client, client-centered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment must be prior authorized. Providers must utilize a national recognized evidencebased practice. Practices include, but are not limited to, Nurturing Parents and Incredible Years. | * Date of Service * Start and stop times of actual encounter with client and spouse/family * Place of service * Participants present * Nature of relationship with client * Rationale for excluding the identified client, if applicable * Diagnosis and pertinent interval history * Rationale and objective used must coincide with the most recent intake assessment and improve the impact the client's condition has on the spouse/family or improve marital/family interactions between the client and the spouse/family, or both * Client and Spouse/family response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * HIPAA compliant Release of Information forms, completed, signed, and dated * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
Information to support the appropriateness of excluding the identified client 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 client and that support's expected role in attaining treatment goals is documented. Only one (1) client per family per therapy session may be billed. | Fifteen (15) minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: Four (4) YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): forty-eight (48) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | A provider can only bill a total of forty-eight (48) units of Psychoeducation The following c services cannot be billed on the Same Date of Service: Marital/Family Behavioral Health Counseling with Client Present Marital/Family Behavioral Health Counseling without Client Present View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurse * Physician * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home),14 (Group Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | 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) clients and their family members or significant others. Services are a more cost-effective alternative to Marital/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 client's (a) Mental Health or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the client, client-centered and strength-based; with emphasis on needs as identified by the client and family and provided with cultural competence. | * Date of Service * Start and stop times of actual encounter with client and/or spouse/family * Place of service * Participants present * Nature of relationship with client * Diagnosis and pertinent interval history * Rationale for and objective used to improve the impact the client's condition has on the spouse/family and/or improve marital/family interactions between the client and the spouse/family. * Client and Spouse/Family response to treatment that includes current progress or regression and prognosis * Any revisions indicated for the diagnosis or medication(s) * Plan for next session, including any homework assignments and/or crisis plans * HIPAA compliant Release of Information 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 ENCOUNTERS THAT MAY BE BILLED: one (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): twelve (12) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | There are twelve (12) total Multi-Family Behavioral Health Counseling encounters allowed per year. The following services cannot be billed on the Same Date of Service: Marital/Family Behavioral Health Counseling without Client Present Marital/Family Behavioral Health Counseling with Client Present Interpretation of Diagnosis Interpretation of Diagnosis, Telemedicine View or print the procedure codes for counseling services. | |
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 * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurse * Physician | 03 (School), 11 (Office), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | 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 psychodiagnostics 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 or telemedicine 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 client, client-centered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. | * Date of Service * Start and stop times of the face-to-face encounter with the client 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 * DSM diagnostic impressions * 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 This service can be provided via telemedicine *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. A Mental Health Diagnosis will be required for all children through forty-seven (47) months of age to receive services. This service includes up to four (4) encounters for children through the age of forty-seven (47) months of age and can be provided without a prior authorization. This service must include an assessment of: * Presenting symptoms and behaviors * Developmental and medical history * Family psychosocial and medical history * Family functioning, cultural and communication patterns, and current environmental conditions and stressors * Clinical interview with the primary caregiver and observation of the caregiver-infant relationship and interactive patterns and * Child's affective, language, cognitive, motor, sensory, selfcare, and social functioning | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults Residents of Long-Term Care | The following codes cannot be billed on the Same Date of Service: Psychiatric Assessment View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDER | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | 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 or advising the client and their family. Services pertain to a client's (a) Mental Health or (b) Substance Abuse condition, or both. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the client, clientcentered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. | * Date of service * Start and stop times of face-to-face encounter with client and/or parent(s) or guardian(s) * Place of service * Participants present and relationship to client * Diagnosis and pertinent interval history * Rationale for and description of the treatment used that must coincide with the most recent intake assessment * Participant(s) response and feedback * Recommendation for additional supports including referrals, resources, and information * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS |
For clients under eighteen (18) years of age, the time may be spent face-to-face with the client; the client and the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For clients over eighteen (18) years of age, the time may be spent face-to-face with the client and the spouse, legal guardian, or significant other. This service can be provided via telemedicine to clients eighteen (18) years of age and above. This service can also be provided via telemedicine to clients seventeen (17) years of age and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record. *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. Interpretation of Diagnosis will be required in order for all children, through forty-seven (47) months of age, to receive services. This service includes up to four (4) encounters for children through forty-seven (47) months of age and can be provided without a prior authorization. The Interpretation of Diagnosis is a direct service that includes an interpretation from a broader perspective, based on 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. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | The following services cannot be billed on the Same Date of Service: Psychoeducation Psychiatric Assessment Multi-Family Behavioral Health Counseling Substance Abuse Assessment View or print the procedure codes for counseling services. This service can be provided via telemedicine to clients eighteen (18) years of age and above. This service can also be provided via telemedicine to clients seventeen (17) years of age 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, Youth and Children | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified, in specific evidence-based practices, to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Alcohol and/or drug assessment | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Substance Abuse Assessment is a service that identifies and evaluates the nature and extent of a client's substance abuse condition using the Addiction Severity Index (ASI) or an assessment instrument approved by DAABHS and DMS. The assessment must screen for and identify any existing co-morbid conditions. The assessment should assign a diagnostic impression to the client, resulting in a treatment recommendation and referral appropriate to effectively treat the condition(s) identified. Services must be congruent with the age and abilities of the client, client-centered, and strength-based; with emphasis on needs, as identified by the client, and provided with cultural competence. | * Date of Service * Start and stop times of the face-to-face encounter with the client 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 * Cultural and age-appropriate psychosocial history and assessment * Mental status (Clinical observations and impressions) * Current functioning and strengths in specified life domains * DSM diagnostic impressions * Treatment recommendations and prognosis for treatment * Staff signature/credentials/date of signature | |
NOTES | UNIT | BENEFIT LIMITS |
The assessment process results in the assignment of a diagnostic impression, client recommendation for treatment regimen appropriate to the condition and situation presented by the client, 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 client for a psychiatric consultation. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | The following codes cannot be billed on the Same Date of Service: Interpretation of Diagnosis View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Licensed Alcoholism and Drug Abuse Counselor Master's | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: A problem focused history; A problem focused examination; or straightforward medical decision making. Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: An expanded problem-focused history; An expanded problem-focused examination; or medical decision making of low complexity. Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: A detailed history, A detailed examination; or medical decision making of moderate complexity. View or print the procedure codes for counseling services. | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Pharmacologic Management is a service tailored to reduce, stabilize, or eliminate psychiatric symptoms, with the goal of improving functioning, including management and reduction of symptoms. This service includes evaluation of the medication prescription, administration, monitoring, and supervision, as well as informing clients regarding potential effects and side effects of medication(s), in order to make informed decisions regarding the prescribed medications. Services must be congruent with the age, strengths, and accommodations necessary for disability and cultural framework. Services must be congruent with the age and abilities of the client, client-centered, and strength-based; with emphasis on needs as identified by the client and provided with cultural competence. | * Date of Service * Start and stop times of actual encounter with client * Place of service * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the Psychiatric Assessment * Client's response to treatment that includes current progress or regression and prognosis * Revisions indicated for the 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 twenty-four (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 Psychiatric Assessment. | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Advanced Practice Nurse * Physician | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office), 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Psychiatric diagnostic evaluation with medical services | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Psychiatric Assessment is a face-to-face psychodiagnostics 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 clients under eighteen (18) years of age). 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 clients to receive counseling services. | * Date of Service * Start and stop times of the face-to-face encounter with the client and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * The interview should obtain or verify the following: 1. The client's understanding of the factors leading to the referral 2. The presenting problem (including symptoms and functional impairments) 3. Relevant life circumstances and psychological factors 4. History of problems 5. Treatment history 6. Response to prior treatment interventions 7. Medical history (and examination as indicated) * For clients under eighteen (18) years of age 1. an interview of a parent (preferably both), the guardian (including the responsible DCFS caseworker), and the primary caretaker (including foster parents) as applicable in order to: a) Clarify the reason for the referral b) Clarify the nature of the current symptoms c) Obtain a detailed medical, family, and developmental history * 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 * 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.). | Encounter | DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults Telemedicine (Adults, Youth, and Children) | The following services cannot be billed on the Same Date of Service: Mental Health Diagnosis View or print the procedure codes for counseling services. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
A. an Arkansas-licensed physician, preferably someone with specialized training and experience in psychiatry (child and adolescent psychiatry for clients under eighteen (18) years of age) B. an Adult Psychiatric Mental Health Advanced Nurse Practitioner/Family Psychiatric Mental Health Advanced Nurse Practitioner (PMHNP-BC) The PMHNP-BC must meet all of the following requirements: A. Licensed by the Arkansas State Board of Nursing B. Practicing with licensure through the American Nurses Credentialing Center C. Practicing under the supervision of an Arkansas-licensed psychiatrist with whom the PMHNP-BC has a collaborative agreement. The findings of the Psychiatric Assessment conducted by the PMHNP-BC, must be discussed with the supervising psychiatrist within forty-five (45) days of the client entering care. The collaborative agreement must comply with all Board of Nursing requirements and must spell out, in detail, what the nurse is authorized to do and what age group they may treat D. Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act E. Practicing within a PMHNP-BC's experience and competency level | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office), 12, (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) | |
PROCEDURE CODES | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Intensive outpatient treatment for alcohol and/or substance abuse. Treatment program must operate a minimum of three (3) hours per day and at least three (3) days per week. The treatment is based on an individualized plan of care 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 (1) 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 apply skills in "real world" environments. Such treatment may be offered during the day, before or after work 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 nine (9) or more hours per week of skilled treatment, three to five (3-5) times per week in groups of no fewer than three (3) and no more than twelve (12) clients. | * Date of service * Start and stop times of the face-to-face encounter with the client 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 * Diagnostic impressions * Rationale for service including consistency with plan of care * Brief mental status and observations * Current functioning and strengths in specified life domains * Client's response to the intervention that includes current progress or regression and prognosis * Staff signature/credentials/date of signature(s) | |
NOTES | UNIT | BENEFIT LIMITS |
Per Diem | YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED: (extension of benefits can be requested) Twenty-four (24) | |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Adults and Youth | A provider may not bill for any other service on the same date of service. | |
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | Counseling | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Intensive Outpatient Substance Abuse Treatment must be provided in a facility that is licensed by the Division of Provider Services and Quality Assurance as an Intensive Outpatient Substance Abuse Treatment Provider. | 11 (Office) 14 (Group Home), 22 (On Campus - OP Hospital), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), | |
PROCEDURE CODES | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Crisis Stabilization service, per fifteen (15) minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Crisis Stabilization Intervention is a scheduled face-to-face (or telemedicine) treatment activity provided to a client who has recently experienced a psychiatric or behavioral health crisis that is expected to further stabilize, prevent deterioration, and serve as an alternative to twenty-four (24) -hour inpatient care. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the client and their family. | * Date of service * Start and stop time of actual encounter with client and possible collateral contacts with caregivers or informed persons * Place of service * Specific persons providing pertinent information and relationship to client * 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 * Client'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 client or others are at risk for imminent harm or in which to prevent significant deterioration of the client's functioning. This service is a planned intervention that MUST be on the client's treatment plan to serve as an alternative to twenty-four (24) -hour inpatient care. | Fifteen (15) minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: Twelve (12) units YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): Seventy-two (72) units |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Crisis | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Licensed Alcoholism and Drug Abuse Counselor Master's * Advanced Practice Nurses * Physicians | 02 (Telemedicine) 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 15 (Mobile Unit), 23 (Emergency Room), 33 (Custodial Care facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic), 99 (Other Location) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Crisis intervention service, per fifteen (15) minutes | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Crisis Intervention is unscheduled, immediate, short-term treatment activities provided to a Medicaid-eligible client 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 client 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 client to determine if the need for crisis services is present.) Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the client and their family. | * Date of service * Start and stop time of actual encounter with client and possible collateral contacts with caregivers or informed persons * Place of service * Specific persons providing pertinent information and relationship to client * 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 * Client'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 client or others are at risk for imminent harm, or in which to prevent significant deterioration of the client's functioning. This service can be provided to clients that have not been previously assessed or have not previously received behavioral health services. No PCP referral is required for crisis intervention The provider of this service MUST complete a Mental Health Diagnosis within seven (7) days of provision of this service, if provided to a client who is not currently a client. View or print the procedure codes for counseling services. If the client cannot be contacted or does not return for a Mental Health Diagnosis appointment, attempts to contact the client must be placed in the client's medical record. If the client needs more time to be stabilized, this must be noted in the client's medical record and the Division of Medical Services Quality Improvement Organization (QIO) must be notified. | Fifteen (15) minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: twelve (12) YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): seventy-two (72) |
APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
Children, Youth, and Adults | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face Telemedicine (Adults, Youth, and Children) | Crisis | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians | 02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 10 (Telehealth Provided in Client's Home), 11 (Office) 12 (Patient's Home), 15 (Mobile Unit), 23 (Emergency Room), 33 (Custodial Care facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic), 99 (Other Location) | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | Behavioral Health; short-term residential | |
SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
Acute Crisis Units provide brief (96 hours or less) crisis treatment services to persons eighteen (18) years of age and over, who are experiencing a psychiatric or substance abuse-related crisis, or both, and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and stepdown services in a safe environment with psychiatry and substance abuse services onsite at all times, as well as on-call psychiatry available twenty-four (24) hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed. | * Date of service * Assessment information including mental health and substance abuse psychosocial evaluation, initial discharge plan, strengths and abilities to be considered for community re-entry * Place of service * Specific persons providing pertinent information and relationship to client * Diagnosis and synopsis of events leading up to acute crisis admission * Interpretive summary * 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 * Client'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 * Thorough discharge plan including treatment and community resources * Staff signature/credentials/date of signature(s) | |
NOTES | EXAMPLE ACTIVITIES | |
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Adults | Per Diem | * Ninety-six (96) hours or less per admission; Extension of Benefits required for additional days |
PROGRAM SERVICE CATEGORY | ||
Crisis Services | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Acute Crisis Units must be certified by the Division of Provider Services and Quality Assurance as an Acute Crisis Unit Provider. | 55 (Residential Substance Abuse Treatment Facility), 56 (Psychiatric Residential Treatment Center | |
CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
View or print the procedure codes for counseling services. | 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 clients by clearing toxins from the client'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 client for ongoing treatment. | * Date of service * Assessment information including mental health and substance abuse psychosocial evaluation, initial discharge plan, strengths and abilities to be considered for community re-entry * Place of service * Specific persons providing pertinent information and relationship to client * Diagnosis and synopsis of events leading up to acute crisis admission * Interpretive summary * 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 * Client'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 * Thorough discharge plan including treatment and community resources * Staff signature/credentials/date of signature(s) | |
NOTES | EXAMPLE ACTIVITIES | |
APPLICABLE POPULATIONS | UNIT | BENEFIT LIMITS |
Youth and Adults | N/A | * Six (6) encounters per SFY; Extension of Benefits required for additional encounters |
PROGRAM SERVICE CATEGORY | ||
Crisis Services | ||
ALLOWED MODE(S) OF DELIVERY | TIER | |
Face-to-face | N/A | |
ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
Substance Abuse Detoxification must be provided in a facility that is licensed by the Division of Provider Services and Quality Assurance as a Substance Abuse Detoxification provider. | 21 (Inpatient Hospital), 55 (Residential Substance Abuse Treatment Facility) | |
To bill for Counseling Services, use the CMS-1500 form. The numbered items correspond to numbered fields on the claim form. View a CMS-1500 sample form.
When completing the CMS-1500, accuracy, completeness, and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be forwarded to the Arkansas Medicaid fiscal agent. View or print 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. |
1a. INSURED'S I.D. NUMBER (For Program in Item 1) | Client'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) | Client's or participant's last name and first name. |
3. PATIENT'S BIRTH DATE SEX | Client's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY. 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) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Optional. Client's or participant's complete mailing address (street address or post office box). Name of the city in which the client or participant resides. Two-letter postal code for the state in which the client or participant resides. Five-digit zip code; nine digits for post office box. The client'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) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Required if insured's address is different from the patient's address. |
8. PATIENT STATUS | Not required. |
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) a. OTHER INSURED'S POLICY OR GROUP NUMBER b. OTHER INSURED'S DATE OF BIRTH SEX c. EMPLOYER'S NAME OR SCHOOL NAME d. INSURANCE PLAN NAME OR PROGRAM NAME | If patient has other insurance coverage as indicated in Field 11d, the other insured's last name, first name, and middle initial. Policy and/or group number of the insured individual. Not required. Not required. Required when items 9 a-d are required. Name of the insured individual's employer and/or school. Name of the insurance company. |
10. IS PATIENT'S CONDITION RELATED TO: | |
a. EMPLOYMENT? (Current or Previous) b. AUTO ACCIDENT? PLACE (State) c. OTHER ACCIDENT? d. RESERVED FOR LOCAL USE | Check YES or NO. Required when an auto accident is related to the services. Check YES or NO. If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. Required when an accident other than automobile is related to the services. Check YES or NO. Not used. |
11. INSURED'S POLICY GROUP OR FECA NUMBER a. INSURED'S DATE OF BIRTH SEX b. EMPLOYER'S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | Not required when Medicaid is the only payer. Not required. Not required. Not required. Not required. 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 | Primary Care Physician (PCP) referral or PCMH sign-off is required for Counseling Services for all clients after ten (10) counseling services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
a. (blank) b. NPI | Not required. Enter NPI of the referring physician. |
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | When the serving/billing provider's services charged on this claim are related to a client's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY. |
19. RESERVED FOR LOCAL USE | Not applicable to Counseling 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" for ICD-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 ORIGINAL REF. NO. | Reserved for future use. Reserved for future use. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24A. DATE(S) OF SERVICE B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES CPT/HCPCS MODIFIER | The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. 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. Two-digit national standard place of service code. See Section 252.200 for codes. Enter "Y" for "Yes" or leave blank if "No". EMG identifies if the service was an emergency. Enter the correct CPT or HCPCS procedure codes from Sections 252.100 through 252.150. 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 client 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. |
I. ID QUAL | Not required. |
J. RENDERING PROVIDER | Enter the 9-digit Arkansas Medicaid provider ID |
ID # | number of the individual who furnished the services billed for in the detail or |
NPI | Enter NPI of the individual who furnished the services billed for in the detail. |
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 a. (blank) b. Service Site Medicaid ID number | Enter the name and street, city, state, and zip code of the facility where services were performed. Not required. Enter the 9-digit Arkansas Medicaid provider ID number of the service site. |
33. BILLING PROVIDER INFO & PH # a. (blank) b. (blank) | Billing provider's name and complete address. Telephone number is requested but not required. Enter NPI of the billing provider or Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
Rules for the Division of Medical Services
Licensure Manual for Community Support System Providers
The purpose of these standards is to:
A CSSP must report all alleged, suspected, observed, or reported occurrences of any of the following events while a client is receiving a home and community-based service:
A CSSP with Enhanced CSSP Agency certification must meet all standards applicable to Base CSSP Agency certification and Intensive CSSP Agency certification in subchapters three (3) through ten (10) in addition to the requirements set out in this subchapter.
The Division of Medical Services (DMS) is authorizing providers to become providers of diagnostic and evaluation services. Diagnostic and evaluation services will be specific to the Divisions of Developmental Disabilities (DDS) and Aging, Adult and Behavioral Health Services (DAABHS), where appropriate to determine eligibility for services (DDS) and treatment planning/diagnostic clarification (DAABHS).
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 client 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 client is eligible for Arkansas Medicaid prior to rendering services.
Services must be billed on a per unit basis as indicated in the service definition, as reflected in a daily total, per client, per service.
In a single claim transaction, a provider may bill only for service time accumulated within a single day for a single client. There is no "carryover" of time from one day to another or from one client to another.
Arkansas Medicaid providesfee schedules on the DMS website. 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 twenty (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 twenty (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 Services 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 fifteen (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 fifteen (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 Services.
Home and Community-Based Services are person-centered care delivered in the home or community to address a functional deficit or limitation. They are designed to keep clients in their communities.
The services outlined in this manual are contained in either the 1915(i) State Plan Amendment or the 1915(c) Community and Employment Supports Waiver for Provider-led Arkansas Shared Savings Entity (PASSE).
Home and Community Based Services are limited to the following populations: PASSE members and Behavioral Health Adults receiving 1915i HCBS services outside of the PASSE.
Providers who perform HCBS under this manual must be certified by the Division of Provider Services and Quality Assurance (DPSQA) or the Division of Developmental Disabilities Services (DDS) as one of the following:
In addition to certification, providers who perform HCBS under this manual must be enrolled in Medicaid, and in good standing.
Providers who serve PASSE members must also be credentialed as a home and communitybased provider with the PASSEs.
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 no more than 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 of (5) five hours per day, of which 90 minutes must be a documented service provided by a Mental Health Professional. If a client member receives other services during the week but also receives Partial Hospitalization, the client member must receive, at a minimum, 20 documented hours of services on no less than (4) four days in that week. Partial Hospitalization can occur in a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All Partial Hospitalization sites must be certified by the Division of Provider Services and Quality Assurance as a Partial Hospitalization Provider. All medically necessary 1905(a) services are covered for EPSDT eligible individuals in accordance with 1905(r) of the Social Security.
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 household of their choosing in the community. In addition, transitional services help individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration.
An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified clients that aimed at long-term recovery and maximization of selfsufficiency, 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 client 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 client 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 client's master treatment plan.
Supportive Employment is designed to help clients acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany clients on interviews and providing ongoing support and/or on-the-job training once the client is employed.
Service settings may vary depending on individual need and level of community integration, and may include the client'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.
Supportive Housing is designed to ensure that clients have a choice of permanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists clients in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; fosters independence; and facilitates the individual's recovery journey. Supportive Housing includes assessing the client's individual housing needs and presenting options, assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history), searching for housing, communicating with landlords, coordinating the move, providing training in how to be a good tenant, and establishing procedures and contacts to retain housing.
Supportive Housing can occur in the following:
* The individual's home;
* In community settings such as school, work, church, stores, or parks; and
* In a variety of clinical settings for adults, similar to adult day cares or adult day clinics.
A service that provides support and training for youth and adults on a one-on-one or group basis. This service should be a strength-based, culturally appropriate process that integrates the member into their community as they develop their recovery plan or habilitation plan. This service is designed to assist members in acquiring the skills needed to support as independent a lifestyle as possible, enable them to reside in their community (in their own home, with family, or in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to assist members 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, socialization, community integration, wellness, and nutrition. For clients with developmental or intellectual disability, supportive life skills development may focus on acquiring skills to complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as communication, bathing, grooming, cooking, shopping, or budgeting.
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 clients to provide education, hope, healing, advocacy, selfresponsibility, 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 clients' functional ability. Services are provided on an individual or group basis, and in either the client's home or community environment.
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.
A plan that is developed in cooperation with the client to deliver specific mental health services to restore, improve, or stabilize the client's mental health condition. Treatment Plans must be updated annually or more frequently if circumstances or needs change significantly, or if the client requests.
Treatment Plans can only be developed by the following clinicians:
A continuum of care provided to recovering members 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 client member to direct their resources and support systems. 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. Meals and transportation are not included in the rate for Aftercare Recovery Support. Aftercare Recovery Support can occur in the following:
* The individual's home;
* In community settings such as school, work, church, stores, or parks; and
* In a variety of clinical settings for adults, similar to adult day cares or adult day clinics.
All medically necessary 1905(a) services are covered for EPSDT eligible members in accordance with 1905(r) of the Social Security Act.
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.
Level 1 provides the highest level of supervision, support and treatment as well as ensuring community safety in a facility of no more than sixteen (16) beds
* Clients who receive this level of care may have treatment needs that are severe enough to require inpatient care in a hospital but don't need the full resources of a hospital setting
* The emphasis in this level is intensive services delivered using a multi-disciplinary approach including physicians, licensed counselors, and highly trained paraprofessionals.
Level 2 provides supervision, support, and treatment, but at a lower level than Level 1 above and can be used as a step down from Level 1 to begin the transition back into a community setting that will not provide twenty-four-hour/seven day (24/7) supervision, service and support
* Interventions shift from clinical to addressing the clients educational or vocational needs, socially dysfunctional behavior, and the need for stable housing
* Arranging for the full array of clinical and HCBS is critical for successful discharge
* Assertive Community Treatment (ACT) would be an ideal step-down service
Assertive Community Treatment (ACT) is an evidence-based practice provided by a multidisciplinary team providing comprehensive treatment and support services available twenty-four (24) hours a day, seven (7) days a week wherever and whenever needed. Services are provided in the most integrated community setting possible to enhance independence and positive community involvement. An individual appropriate for services through an ACT team has needs that are so pervasive and/or unpredictable that it is unlikely that they can be met effectively by other combinations of available community services, or in circumstances where other levels of outpatient care have not been successful to sustain stability in the community. Typically, this service is targeted to individuals who have serious mental illness or co-occurring disorders, multiple diagnoses, and the most complex and expensive treatment needs.
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.
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 as a permanent solution to problem difficult behaviors at school.
Crisis Stabilization Intervention is a scheduled face-to-face treatment activity provided to a client who has recently experienced a psychiatric or behavioral health crisis that is expected to further stabilize, prevent deterioration, and serve as an alternative to twenty-four (24) -hour inpatient care. Services are to be congruent with the age, strengths, needed accommodation for any disability and cultural framework of the member and his/her family. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration, and scope than those services available to a medically needy client, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services.
Assertive Community Treatment (ACT) is an evidence-based practice provided by a multidisciplinary team providing comprehensive treatment and support services available twenty-four (24) hours a day, seven (7) days a week wherever and whenever needed. Services are provided in the most integrated community setting possible to enhance independence and positive community involvement. An individual appropriate for services through an ACT team has needs that are so pervasive and/or unpredictable that it is unlikely that they can be met effectively by other combinations of available community services, or in circumstances where other levels of outpatient care have not been successful to sustain stability in the community. Typically, this service is targeted to individuals who have serious mental illness or co-occurring disorders, multiple diagnoses, and the most complex and expensive treatment needs.
Intensive In-Home service for children is a team approach that is used to address serious and chronic emotional or behavioral issues for children (youth) who are unable to remain stable in the community without intensive interventions. Services are multifaceted: counseling, skills training, interventions, or resource coordination, and are delivered in the client's home or in a community setting. The parent or caregiver must be an active participant in the treatment and individualized services that are developed in full partnership with the family. IIH team provides a variety of interventions that are available at the time the family needs. These interventions include "first responder" crisis response, as indicated in the care plan: twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year. The licensed professional is responsible for monitoring and documenting the status of the client's progress and the effectiveness of the strategies and interventions outlined in the care plan. The licensed professional then consults with identified medical professionals (such as primary care and psychiatric) and non-medical providers (child welfare and juvenile justice), engages community and natural supports, and includes their input in the care planning process.
Intensive In-Home service must be a recognized model of care, clearly outline the duration and scope and be prior approved by a PASSE.
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 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 array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified clients that aimed at long-term recovery and maximization of selfsufficiency, 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 client 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 client 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 client's master treatment plan.
Peer Support is a consumer centered service provided by individuals (ages eighteen (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 clients 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 clients' functional ability. Services are provided on an individual or group basis, and in either the client's home or community environment.
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.
A service provided by peer counselors, of Family Support Partners (FSP), who model recovery and resiliency for caregivers of children and youth with behavioral health care needs or developmental disabilities. FSP 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 and maintain independence. A FSP may assist, teach, and model appropriate child-rearing strategies, techniques, and household management skills. This service provides information on child development, age-appropriate behavior, parental expectations, and childcare activities. It may also assist the member's family in securing resources and developing natural supports.
Family Support Partners serve as a resource for families with a child, youth, or adolescent receiving behavioral health or developmental disability 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 techniques, and self-help skills.
A specific, time limited one-to-one intervention by a nurse with a client and/or caregivers, related to their psycho-pharmacological treatment. Pharmaceutical Counseling involves providing medication information orally or in written form to the client and/or caregivers. The service should encompass all the parameters to make the client and/or family understand the diagnosis prompting the need for the medication and any lifestyle modification required.
Temporary direct care and supervision for a client due to the absence or need for relief of the non-paid primary caregiver. Respite can occur at medical or specialized camps, day-care programs, the member's home or place of residence, the respite care provider's home or place of residence, foster homes, or a licensed respite facility. Respite does not have to be listed in the PCSP. The primary purpose of Respite is to relieve the member's principal care giver of the member with a behavioral health need so that stressful situations are de-escalated, and the care giver and member have a therapeutic and safe outlet. Respite must be temporary in nature. Any services provided for less than fifteen (15) days will be deemed temporary. Respite provided for more than fifteen (15) days should trigger a need to review the PCSP.
A service that provides support and training for youth and adults on a one-on-one or group basis. This service should be a strength-based, culturally appropriate process that integrates the member into their community as they develop their recovery plan or habilitation plan. This service is designed to assist members in acquiring the skills needed to support as independent a lifestyle as possible, enable them to reside in their community (in their own home, with family, or in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to assist members 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, socialization, community integration, wellness, and nutrition. For clients with developmental or intellectual disability, supportive life skills development may focus on acquiring skills to complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as communication, bathing, grooming, cooking, shopping, or budgeting.
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.
Services might include an In-Home Case Aide. An In-Home Case Aide is an intensive, timelimited therapy for youth in the client's home or, in rare instances, a community-based setting. Youth served may be in imminent risk of out-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.
Supportive Employment is designed to help clients acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany clients on interviews and providing ongoing support and/or on-the-job training once the client is employed.
Service settings may vary depending on individual need and level of community integration, and may include the client'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.
Supportive Housing is designed to ensure that clients have a choice of permanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists clients in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; fosters independence; and facilitates the individual's recovery journey. Supportive Housing includes assessing the client's individual housing needs and presenting options, assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history), searching for housing, communicating with landlords, coordinating the move, providing training in how to be a good tenant, and establishing procedures and contacts to retain housing.
Supportive Housing can occur in the following:
* The individual's home;
* In community settings such as school, work, church, stores, or parks; and
* In a variety of clinical settings for adults, similar to adult day cares or adult day clinics.
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 twenty-four (24) hour basis. The environment at this level of treatment is highly structured and should maintain a staff-to-patient ratio of no more than one to five (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 of five (5) hours per day, of which ninety (90) minutes must be a documented service provided by a Mental Health Professional. If a client member receives other services during the week but also receives Partial Hospitalization, the client member must receive, at a minimum, twenty (20) documented hours of services on no less than four (4) days in that week. Partial Hospitalization can occur in a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All Partial Hospitalization sites must be certified by the Division of Provider Services and Quality Assurance as a Partial Hospitalization Provider. All medically necessary 1905(a) services are covered for EPSDT eligible individuals in accordance with 1905(r) of the Social Security
A home or family setting that that consists of high intensive, individualized treatment for the member whose behavioral health or developmental disability needs are severe enough that they would be at risk of placement in a restrictive residential setting.
A therapeutic host parent is trained to implement the key elements of the member's PCSP in the context of family and community life, while promoting the PCSP's overall objectives and goals. The host parent should be present at the PCSP development meetings and should act as an advocate for the member.
A continuum of care provided to recovering members 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 client member to direct their resources and support systems. 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. Meals and transportation are not included in the rate for Aftercare Recovery Support.
Aftercare Recovery Support can occur in the following:
* The individual's home;
* In community settings such as school, work, church, stores, or parks; and
* In a variety of clinical settings for adults, similar to adult day cares or adult day clinics.
All medically necessary 1905(a) services are covered for EPSDT eligible members in accordance with 1905(r) of the Social Security Act.
A set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize the member by clearing toxins from his or her body. Detoxification (detox) services are short term and may be provided in a crisis unit, inpatient, or outpatient setting. Detox services may include evaluation, observation, medical monitoring, and addiction treatment. The goal of detox is to minimize the physical harm caused by the abuse of substances and prepare the member for ongoing substance abuse treatment.
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.
Level 1 provides the highest level of supervision, support and treatment as well as ensuring community safety in a facility of no more than sixteen (16) beds
* Clients who receive this level of care may have treatment needs that are severe enough to require inpatient care in a hospital but don't need the full resources of a hospital setting
* The emphasis in this level is intensive services delivered using a multi-disciplinary approach include physicians, licensed counselors, and highly trained paraprofessionals.
Level 2 provides supervision, support, and treatment, but at a lower level than Level 1 above and can be used as a step down from Level 1 to begin the transition back into a community setting that will not provide twenty-four-hour/seven day (24/7) supervision, service and support
* Interventions shift from clinical to addressing the clients educational or vocational needs, socially dysfunctional behavior, and the need for stable housing
* Arranging for the full array of clinical and HCBS is critical for successful discharge
* Assertive Community Treatment (ACT) would be an ideal step-down service
The Residential Community Reintegration Program is designed to serve as an intermediate level of care between Inpatient Psychiatric Facilities and home and community-based behavioral health services. The program provides twenty-four (24) hour per day intensive therapeutic care provided in a small group home setting for children and youth with emotional and/or behavior problems which cannot be remedied by less intensive treatment. The program is intended to prevent acute or sub-acute hospitalization of youth, or incarceration. The program is also offered as a step-down or transitional level of care to prepare a youth for less intensive treatment. A Residential Community Reintegration Program shall be appropriately certified by the Department of Human Services to ensure quality of care and the safety of clients and staff.
A Residential Community Reintegration Program shall ensure the provision of educational services to all clients in the program. This may include education occurring on campus of the Residential Community Reintegration Program or the option to attend a school off campus if deemed appropriate in accordance with the Arkansas Department of Education.
CES Supported Employment is a tailored array of services that offers ongoing support to members with the most significant disabilities to assist in their goal of working in competitive integrated work settings for at least minimum wage. It is intended for individuals for whom competitive employment has not traditionally occurred, or has been interrupted or intermittent as a result of a significant disability, and who need ongoing supports to maintain their employment.
CES Supported Employment includes any combination of the following services:
Vocational/job related discovery and assessment, person centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instructions, job coaching, benefits support, training and planning, transportation, asset development, and career advancement services, extended supported employment supports, and other workplace support services including services not specifically related to job skill training that enable the waiver client to be successful in integrating into the job setting. The service array may also be utilized to support individuals who are self-employed.
Transportation between the member's place of residence and the employment site is included as a component of supported employment services when there is no other resource for transportation available.
Supportive living is an array of individually tailored services and activities to enable members to reside successfully in their own home, with family or in an alternative living setting (apartment, or provider owned group home). Supportive living services must be provided in an integrated community setting.
Supportive living includes care, supervision, and activities that directly relate to active treatment goals and objectives set forth in the member's PCSP. It excludes room and board expenses, including general maintenance, upkeep, or improvement to the home.
Supportive living supervision and activities are meant to assist the member to acquire, retain, or improve skills in a wide variety of areas that directly affect the person's ability to reside as independently as possible in the community. The habilitation objective to be served by each activity should be documented in the member's PCSP. Examples of supervision and activities that may be provided as part of supportive living include:
Individuals who receive supportive living and require a higher level of care to acuity may receive supportive living in congregant home settings of no more than eight (8) unrelated persons.
Each client residing in the Complex Care Home must be diagnosed with an intellectual disability and a significant co-occurring deficit, which includes without limitation individuals with an intellectual disability and significant:
A Provider is required to maintain the client to staff ratio required to meet each client's needs as provided in their Person Centered Service Plan and ensure client and staff health and safety, but under no circumstances may there be less than a four-to-one (4:1) client to staff ratio in the home at any time.
Adaptive equipment is a piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of members, whether commercially purchased, modified, or customized. The adaptive equipment services include adaptive, therapeutic, or augmentative equipment that enables a member to increase, maintain, or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
Consultation by a medical professional must be conducted to ensure the adaptive equipment will meet the needs of the member.
Adaptive equipment includes enabling technology, such as safe home modifications, that empower members to gain independence through customizable technologies that allow them to safely perform activities of daily living without assistance while still providing monitoring and response for those members, as needed. Enabling technology allows members to be proactive about their daily schedule and integrates member choice.
Adaptive equipment also includes Personal Emergency Response Systems (PERS), which is a stationary or portable electronic device used in the member's place of residence and that enables the member to secure help in an emergency. The system is connected to a response center staffed by trained professionals who respond to activation of the device. PERS services may include the assessment, purchase, installation, and monthly rental fee.
Computer equipment, including software, can be included as adaptive equipment. Specifically, computer equipment includes equipment that allows the member increased control of their environment, to gain independence, or to protect their health and safety.
Vehicle modifications are also included as adaptive equipment. Vehicle modifications are adaptions to an automobile or van to accommodate the special needs of the member. The purpose of vehicle modifications is to enable the member to integrate more fully into the community and to ensure the health, safety, and welfare of the member. Vehicle modifications exclude: adaptations or modifications to the vehicle that are of general utility and not of direct medical or habilitative benefit to the member; purchase, down payment, monthly car payment or lease payment; or regularly scheduled maintenance of the vehicle.
Community Transition Services are non-recurring set-up expenses for members who are transitioning from an institutional or provider-operated living arrangement, such as an ICF or group home, to a living arrangement in a private residence where the member or his or her guardian is directly responsible for his or her own living expenses.
Community Transition service activities include those necessary to enable a member to establish a basic household, not including room and board, and may include:
Community Transition Services should not include payment for room and board; monthly rental or mortgage expense; regular food expenses, regular utility charges; and/or household appliances, or items that are intended for purely diversional/recreational purposes.
Consultation services are clinical and therapeutic services which assist the individual, parents, legally responsible persons, responsible individuals, and service providers in carrying out the member's PCSP. These services are direct in nature. The PASSE will be responsible for maintaining the necessary information to document staff qualifications. Staff, who meets the certification criteria necessary for other consultation functions, may also provide these activities.
These activities include, but are not limited to:
Modifications made to the member's place of residence that are necessary to ensure the health, welfare, and safety of the member or that enable the member to function with greater independence and without which, the member would require institutionalization. Examples of environmental modifications include the installation of wheelchair ramps, widening doorways, modification of bathroom facilities, installation of specialized electrical and plumbing systems to accommodate medical equipment, installation of sidewalks or pads, and fencing to ensure nonelopement, wandering, or straying of members with decreased mental capacity or aberrant behaviors.
Exclusions include modifications or repairs to the home which are of general utility and not for a specific medical or habilitative benefit; modifications or improvements which are of an aesthetic value only; and modifications that add to the total square footage of the home.
Environmental modifications that are permanent fixtures to rental property require written authorization and release of current or future liability from the property owner.
Supplemental Support services meet the needs of the client to improve or enable the continuance of community living. Supplemental Support Services will be based upon demonstrated needs as identified in a member's PCSP as unforeseen problems arise that, unless remedied, could cause a disruption in the member's services or placement, or place the member at risk of institutionalization.
Respite services are provided periodically on a short term basis in accordance with the member's PCSP. They may be provided in an emergency situation due to the absence of or need for relief to the no-paid primary caregiver. Respite services may include the cost of room and board charges when allowable.
Receipt of respite does not necessarily preclude a member from receiving other services on the same day. For example, a member may receive day services, such as supported employment, on the same day as caregiver respite services.
When caregiver respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Caregiver respite should not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Caregiver respite services are not to supplant the responsibility of the parent or guardian.
Specialized medical equipment and supplies include:
Additional supply items are covered as a Waiver service when they are considered essential and medically necessary for home and community care;
Home and Community-Based Services outlined in this Manual for the Behavioral Health Adults receiving HCBS services outside of the PASSE are reimbursed on a fee for service basis by Medicaid. Service rates are set on a unit or daily rate basis. A full unit or day must be rendered in order to bill a unit of service.
Arkansas Medicaid provides fee schedules on the DMS website. 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.
Medicaid covers behavioral health services when furnished by qualified providers to eligible Medicaid beneficiaries. A primary care physician referral is required for some behavioral health services when provided outside the physician's office.
For additional information about services that may not require PCP referral, refer to Section 172.100 of this manual.
The counseling procedures covered under the Physician Program are allowed as a covered service for providers enrolled in the Primary Care Case Management (PCCM) program and when provided by the physician or by a qualified practitioner authorized by State licensure to provide them. For additional information about qualified practitioners who can provide counseling services, refer to Section II of the Counseling Services Medicaid Provider Manual.
When a practitioner other than a physician provides the services, the practitioner must be under supervision of a physician in the clinic that is billing for the services. For counseling services only, the term supervision means the following:
And
Refer to Section 292.740 of this manual for more information.
The counseling procedures covered under the Physician Program are allowed as a covered service when provided by the physician or when provided by a qualified practitioner who by State licensure is authorized to provide them.
Counseling Services must be provided by a physician or qualified performing provider in the physician's office or the outpatient hospital. Counseling codes may not be billed in conjunction with an inpatient hospital visit, or inpatient psychiatric facility visit and may not be billed when services are performed as Medicaid Behavioral Health Counseling Services at another enrolled Arkansas Medicaid provider type site. Only one (1) counseling visit per day is allowed in the physician's office, the outpatient hospital, or nursing home. Counseling Services provided and billed by a physician's office are defined in the Arkansas Medicaid Counseling Services provider manual. The rules set forth in the Counseling Services manual will apply with the exception of the place of service codes. Place of service will be limited to the following place of service codes: Place of Service Code 22 Outpatient Hospital, 11 Doctor's Office and 12 Patient's Home. Any additional services provided by a psychiatrist enrolled in the physician's program will count against the sixteen (16) visits per State Fiscal Year physician benefit limit. Record Review is not covered.
A physician, physician's assistant, or advanced nurse practitioner may administer a brief standardized emotional/behavioral assessment screening to a client along with an office visit. The allowable screening is up to two (2) units per visit and is allowable up to four (4) times per state fiscal year without prior authorization. An extension of benefits may be requested if additional screening is medically necessary. If a client is under the age of eighteen (18), and the parent/legal guardian appears depressed, he or she can be screened as well, and the screening billed under the minor's Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counseling screening limit. The physician must have the capacity to treat or refer the parent/guardian for further treatment if the screening results indicate a need, regardless of payor source.
016.29.22 Ark. Code R. § 016