D.C. Mun. Regs. r. 22-A3434
Reimbursement for the provision of MHRS shall be on a per unit basis as indicated in § 3434.4.
Each covered service shall have a unique billing code as established by the Department.
The actual start and stop time of the service shall be used to calculate the duration of the service rounded to the nearest fifteen-minute unit.
Reimbursement shall be limited as follows:
MHRS | LIMITATIONS AND SERVICE SETTING | BILLABLE UNIT OF SERVICE |
Diagnostic Assessment | * One (1) every one-hundred eighty (180) calendar days. * Additional units allowable when there is a significant change in the consumer's mental health status. * Shall not be billed the same day as ACT. * Provided only in an MHRS provider's service site, home or community setting, or residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | An assessment, which is at least three (3) hours in duration |
Medication/ Somatic Treatment | * No annual limits. * Shall not be billed the same day as ACT or IDT. * Provided only in an MHRS provider's service site, home or community setting, via telemedicine, or in a residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) Minutes |
Counseling | * One-hundred sixty (160) units per twelve (12) month period. * Additional units allowable with prior authorization. * Shall not be billed the same day as IDT, CBI, ACT, TF-CBT, or TST. * Shall not be billed during a Rehabilitation Day Services encounter. * Shall be rendered face-to-face, when consumer is present, unless there is adequate documentation to justify why the consumer was not present during the session. * May be provided in individual on-site, individual off-site, or group. * Provided only in an MHRS provider's service site, home or community setting, via telemedicine, or in a residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) Minutes |
Community Support | * Six-hundred (600) units per one-hundred eighty (180) calendar days. * Additional units allowable with prior authorization; each authorization cannot exceed two-hundred (200) units per one-hundred eighty (180) calendar days. * Shall not be billed on the same day as ACT. * Individual Community Support shall not be billed during a Rehabilitation Day Services encounter. * Group Community Support shall not be billed on the same day as Rehabilitation Day Services. * Provided only in an MHRS provider's service site, home, community setting, or residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) minutes |
Crisis/ Emergency Services | * No annual limits. * ACT providers shall not bill Crisis/Emergency Services when provided to one of their current consumers. * Provided only in an MHRS provider's service site, home or community setting, or via telehealth. * Provided by a Core Service Agency to their enrolled consumers. | Fifteen (15) minutes |
Rehabilitation Day Services | * Ninety (90) units within a twelve (12) month period. * Additional units allowable with prior authorization; each authorization cannot exceed ninety (90) units per twelve (12) month period. * Shall not be billed on the same day as Group Community Support, ACT, IDT, TF-CBT, TREM, TST, or Clubhouse. * Shall not be billed during a Counseling or Individual Community Support encounter. * Provided only in an MHRS provider's service site. | One (1) day (which shall consist of at least three (3) hours of service, excluding appropriate time for breaks and administrative functions) |
IDT | * Prior authorization required. Initial and subsequent authorizations shall not exceed seven (7) days at a time. * Shall not be billed on the same day as Medication/Somatic Treatment, Counseling, Rehabilitation Day Services, ACT, TF-CBT, TREM, TST, Clubhouse, or Supported Employment Services as defined in Title 22-A DCMR Chapter 37. * Provided only in an MHRS provider's service site. | One (1) day (which shall consist of at least five (5) hours of IDT services, excluding appropriate time for breaks and administrative functions) |
CBI | * Prior authorization required for enrollment and continued stay (see § 3425 for details). * Shall not be billed on the same day as Counseling, ACT, FFT, or TF-CBT. * CBI Level II and III shall not be billed on the same day as TREM. * Provided only in an MHRS provider's service site, or home or community setting. | Fifteen (15) minutes |
ACT | * Prior authorization required. Initial and subsequent authorizations shall not exceed one-hundred eighty (180) calendar days and five-hundred (500) units. * Shall not be billed on the same day as Diagnostic Assessment, Medication/Somatic Treatment, Counseling, Community Support, Rehabilitation Day Services, IDT, CBI, FFT, TF-CBT, TREM, or TST. * ACT providers shall not bill Crisis/Emergency Services if provided to one of their current consumers. * ACT providers must deliver eight (8) contacts per calendar month as defined in § 3426.19 and meet the requirements of § 3426.20 through § 3426.2 to receive the monthly rate. * ACT Services delivered by an MD or APRN may be provided via telemedicine pursuant to 29 DCMR § 910. All other ACT services must be provided in an MHRS provider's service site, home or community setting. | Monthly rate |
CPP | * May be provided without prior authorization. * Shall not be billed on the same day as TF-CBT or TST. * Provided only in an MHRS provider's service site, home or community setting, or residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) minutes up to ninety (90) minutes once (1) per week |
TF-CBT | * May be provided without prior authorization. * Shall not be billed the same day as Counseling, Rehabilitation Day Services, IDT, CBI, FFT, ACT, CPP, or TST. * Provided only in an MHRS provider's service site, home or community setting, or residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) minutes up to ninety (90) minutes once (1) per week |
TREM | * May be provided without prior authorization. * TREM shall not be billed on the same day as Rehabilitation Day Services, IDT, CBI Levels II and III, or ACT. * Provided only in an MHRS provider's service site, or residential facility of sixteen (16) beds or less unless otherwise approved by the Department. | Fifteen (15) minutes |
TST | * May be provided without prior authorization. * TST shall not be billed on the same day as Counseling, Rehabilitation Day Services, IDT, FFT, ACT, CPP, or TF-CBT. | Fifteen (15) minutes |
FFT | * May be provided without prior authorization. * Shall not be billed on the same day as CBI, Community Support, TF-CBT, or TST. | Fifteen (15) minutes |
CCC | * No annual limits. * May be provided without prior authorization. * ACT providers shall not bill CCC when provided to one of their current consumers. * May be provided in an MHRS provider's service site, home or community setting, or via telehealth. * A provider may only claim one service if multiple clinicians from that provider agency participate in the CCC service. | Fifteen (15) minutes |
All claims seeking Medicaid or local only reimbursement under this Chapter shall include the active NPI numbers for the certified provider and the rendering provider. The rendering provider is the staff member who provided the service.
D.C. Mun. Regs. r. 22-A3434