Mental Health Centers / Prepaid Mental Health Plans

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1 SECTION 2 Table of Contents 1. GENERAL POLICY Authority Qualified Mental Health Providers Definitions Scope of Services Provider Qualifications Evaluation Procedures Treatment Plan Periodic Review of the Treatment Plan Documentation Quality Improvement Collateral Services Billings (Updated 10/1/12) SCOPE OF SERVICES General Limitations Psychiatric Diagnostic Interview Examination Mental Health Assessment by a Non-Mental Health Therapist Psychological Testing Individual Psychotherapy and Individual Psychotherapy with Medical Evaluation and Management Services Family Psychotherapy Group Psychotherapy Pharmacologic Management Therapeutic Behavioral Services Psychosocial Rehabilitative Services Peer Support Services (b)(3) SERVICES FOR PREPAID MENTAL HEALTH PLAN CONTRACTORS ONLY Page 1 of 49 SECTION 2

2 3-1 Personal Services Respite Care Psychoeducational Services Supportive Living PROCEDURE CODES AND MODIFIERS FOR REHABILITATIVE MENTAL HEALTH SERVICES Mental Health Assessment by a Non-Mental Health Therapist Psychological Testing Individual Psychotherapy Family Psychotherapy Group Psychotherapy Pharmacologic Management Group Psychosocial Rehabilitative Services PROCEDURE CODES FOR 1915(b)(3) SERVICES PREPAID MENTAL HEALTH PLAN CONTRACTORS ONLY Psychoeducational Services Supportive Living INDEX Page 2 of 49 SECTION 2

3 1. GENERAL POLICY 1-1 Authority Rehabilitative mental health services are provided under the authority of 42 CFR , Diagnostic, Screening, Preventive, and Rehabilitative Services. Under this authority, services may be provided in settings other than the provider s office, as appropriate, with the exception of an inpatient hospital. 1-2 Qualified Mental Health Providers Rehabilitative mental health services are covered benefits when provided by or through a mental health center (or other entity) under contract with or directly operated by a local county mental health authority. Children in State Custody For the provision of outpatient services to children in state custody, mental health centers/prepaid Mental Health Plan providers may follow this provider manual. However, children in state custody must have more frequent reviews of their treatment plans. The review schedule for children in state custody is outlined in Chapter 1-8, Periodic Review of the Treatment Plan. 1-3 Definitions Children in Foster Care: Means children and youth under the statutory responsibility of the Utah Department of Human Services identified as such in the Medicaid eligibility (erep) system. Habilitation Services: typically means interventions for the purpose of helping individuals acquire new functional abilities whereas rehabilitative services are for the purpose of restoring functional losses. (See Rehabilitative Services definition below.) Medically Necessary Services: means any mental health service that is necessary to diagnose, correct or ameliorate a mental illness or condition, or prevent deterioration of that mental illness or condition or development of additional health problems and there is no other equally effective course of treatment available or suitable that is more conservative or substantially less costly. Non-Traditional Medicaid Plan: means the reduced benefits plan provided to Medicaid-eligible adults age 19 through age 64 who: 1) Are not blind, disabled, or pregnant; 2) Are in a Medically Needy aid category and are not blind, disabled, or pregnant; or 3) Are in a Transitional Medicaid aid category. Non-Traditional Medicaid Plan enrollees are in Utah s Section 1115 Primary Care Network Demonstration Program. These individuals Medicaid cards specify they are enrolled in the Non- Traditional Medicaid Plan. Services covered under this reduced benefit plan are similar to the Traditional Medicaid Plan with some limitations and exclusions. Page 3 of 49 SECTION 2

4 Prepaid Mental Health Plan (PMHP): means the Medicaid managed care plan that is responsible for all needed inpatient and outpatient mental health care for Medicaid clients living in certain geographic areas of the state. Medicaid clients enrolled in the PMHP must receive inpatient and outpatient mental health services through PMHP contractors paid on a capitation basis. Children in state custody, and children with an adoption subsidy exempted from the PMHP, are not enrolled in the PMHP for outpatient mental health services; they are only enrolled in the PMHP for inpatient mental health services. Rehabilitative Services: means in accordance with 42 CFR , any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice under State law, for maximum reduction of a physical or mental disability and restoration of a recipient to his best possible functional level. Traditional Medicaid Plan: means the scope of services contained in the State Plan provided to Medicaid-eligible individuals who fall under one of the following Medicaid aid groups: 1) Section 1931 children and related poverty-level population under age 19; 2) Section 1931 pregnant women; 3) Blind or disabled children and related populations; 4) Blind or disabled adults and related populations under age 65; 5) Aged adults age 65 and older and related populations (SSI, QMB and Medicaid, Medicare and Medicaid); 6) Children in Foster Care; 7) Individuals who qualify for Medicaid by paying a spenddown and are under age 19; or 8) Individuals who qualify for Medicaid by paying a spenddown and are also blind or disabled. These individuals Medicaid cards specify they are enrolled in the Traditional Medicaid Plan. 1-4 Scope of Services The scope of rehabilitative mental health services includes the following: - Psychiatric Diagnostic Interview Examination - Mental Health Assessment by a Non-Mental Health Therapist - Psychological Testing - Individual Psychotherapy - Individual Psychotherapy with Medical Evaluation and Management Services - Family Psychotherapy with patient present - Family Psychotherapy without patient present Page 4 of 49 SECTION 2

5 - Group Psychotherapy - Multiple-Family Group Psychotherapy - Pharmacologic Management - Therapeutic Behavioral Services - Psychosocial Rehabilitative Services - Peer Support Services Rehabilitative mental health services are limited to medically necessary services designed to promote the client s mental health, reduce the client s mental disability, restore the client to the highest possible level of functioning, promote the client s self-sufficiency, and systematically reduce the client s reliance on mental health support systems. Note: Rehabilitative substance abuse services are not included under this provider manual. (See the Medicaid provider manual entitled Substance Abuse Treatment Services and Targeted Case Management for Substance Abuse that details the Medicaid fee-for-service substance abuse program.) See Chapter 2, Scope of Services, for service definitions and limitations. 1-5 Provider Qualifications A. Providers Qualified to Prescribe Services Rehabilitative services must be prescribed by an individual defined below: 1. licensed mental health therapist practicing within the scope of his or her license in accordance with Title 58 of the Utah Code: a. licensed physician and surgeon or osteopathic physician engaged in the practice of mental health therapy; b. licensed psychologist qualified to engage in the practice of mental health therapy; c. licensed clinical social worker; d. licensed certified social worker under the supervision of a licensed clinical social worker; e. licensed advanced practice registered nurse (APRN), either as a nurse specialist or a nurse practitioner, with psychiatric mental health nursing specialty certification; f. licensed marriage and family therapist; g. licensed professional counselor; or Page 5 of 49 SECTION 2

6 2. an individual who is working within the scope of his or her certificate or license in accordance with Title 58 of the Utah Code: a. certified psychology resident under the supervision of a licensed psychologist qualified to engage in the practice of mental health therapy; b. licensed APRN formally working toward psychiatric mental health nursing specialty certification through enrollment in a specialized mental health education program or through completion of post-education clinical hours under the supervision of a licensed APRN with psychiatric mental health nursing specialty certification; c. licensed APRN intern formally working toward psychiatric mental health nursing specialty certification and accruing the required clinical hours for the specialty certification under the supervision of a licensed APRN with psychiatric mental health nursing specialty certification; d. associate marriage and family therapist under the supervision of a licensed marriage and family therapist; e. associate professional counselor under the supervision of a licensed mental health therapist except a certified social worker; or 3. an individual exempted from licensure: a. a student enrolled in an education/degree program leading to licensure in one of the professions above, not currently licensed but exempted from licensure under Title 58 of the Utah Code, because of enrollment in qualified courses, internship or practicum, and under the supervision of qualified faculty, staff, or designee. [See Title (1)(b).]; or b. an individual who was employed as a psychologist by a state, county or municipal agency or other political subdivision of the state prior to July 1, 1981, and who subsequently has maintained employment as a psychologist in the same state, county, or municipal agency or other political subdivision while engaged in the performance of his official duties for that agency or political subdivision. [See Title (2)(h).] B. Providers Qualified to Render Services In accordance with the provider limitations set forth in Chapter 2, Scope of Services, rehabilitative services may be provided by: 1. individuals identified in A of this chapter; 2. one of the following individuals working within the scope of his or her certificate or license in accordance with Title 58 of the Utah Code: a. licensed social service worker; or individual working toward licensure as a social service worker; b. licensed registered nurse; c. licensed practical nurse; Page 6 of 49 SECTION 2

7 d. licensed physician and surgeon or osteopathic physician regardless of specialty, or other medical practitioner licensed under state law (e.g., licensed physician assistants when practicing within their scope of practice and under the delegation of services agreement required by their practice act); or e. licensed APRN or licensed APRN intern regardless of specialty. 3. registered nursing student enrolled in an education/degree program leading to licensure, not currently licensed but exempted from licensure under Title 58 of the Utah Code, because of enrollment in qualified courses, internship, or practicum, and under the supervision of qualified faculty, staff, or designee. [See Title (1)(b)]; or 4. other trained individual. (See D of this Chapter below for training requirements.) C. Supervision See Chapter 2, Scope of Services, for service-specific supervision requirements. For certified social workers specified in A 1, individuals specified in A 2 and 3, and individuals specified in B 2 and 3 above, the mental health center/prepaid Mental Health Plan provider must ensure supervision is provided in accordance with requirements set forth in Title 58 of the Utah Code and the applicable profession s practice act rule as set forth by the Utah Department of Commerce and found at the Department of Administrative Services, Division of Administrative Rules, at: D. Training Requirements for Other Trained Individuals Other trained individuals may provide psychosocial rehabilitative services (see Chapter 2-10) and PMHPspecific 1915(b)(3) services: psychoeducational services, personal services, respite care and supportive living (see Chapter 3). These individuals must receive training in order to be a qualified provider. The mental health center/prepaid Mental Health Plan contractor must ensure the following minimum training requirements are met: 1. Individuals shall receive training on all administrative policies and procedures of the agency, and the program as applicable, including: Fraud, waste or abuse detection and reporting; HIPAA and confidentiality/privacy policy and procedures; Emergency/crisis procedures; and Other relevant administrative-level subjects. 2. Individuals shall also receive information and training in areas including: Philosophy, objectives, and purpose of the service(s) the individual will be delivering; Medicaid definition of the service(s) the individual will be delivering; Treatment plans and development of treatment goals; Role and use of clinical supervision of the other trained individual; Specific job duties; Population(s) served and the functional impacts of diagnoses that result in the need for the service; Healthy interactions with clients to help them obtain goals; Page 7 of 49 SECTION 2

8 Management of difficult behaviors; Medications and their role in treatment; Any formal programming materials used in the delivery of the service (the individual shall understand their use and receive training on them as required); and Other relevant subjects as determined by the agency. 3. The hiring body shall maintain documentation of training including dates of training, agendas and training/educational materials used. 4. Training may be provided 90 calendar days prior to or after the publication of these guidelines for existing providers. New providers must complete all training within 60 calendar days of the hiring date. 1-6 Evaluation Procedures In accordance with state law, individuals identified in A of Chapter 1-5 are qualified to conduct an evaluation (psychiatric diagnostic interview examination). An evaluation must be conducted to assess the existence, nature, or extent of illness, injury or other health deviation for the purpose of determining the client s need for medically necessary services. (See Chapter 2-2, Psychiatric Diagnostic Interview Examination.) 1-7 Treatment Plan A. If it is determined that services are medically necessary, an individual identified in A of Chapter 1-5 must develop a treatment plan. B. The treatment plan is a written, individualized plan which contains measurable treatment goals related to problems identified in the psychiatric diagnostic interview examination. The treatment plan must be designed to improve and/or stabilize the client s condition. C. The treatment plan must include the following: 1. measurable treatment goals; If the treatment plan contains psychosocial rehabilitative services, and for PMHPs, 1915b(3) services, there must be measurable goals specific to all issues being addressed with these treatment methods. Actual treatment goals may be developed by qualified providers identified in the Who section in Chapter 2-10 Psychosocial Rehabilitative Services, and in Chapter 3, and they may be documented in an addendum to the treatment plan; 2. the treatment regimen the specific treatment methods (as contained in Chapter 1-4 and Chapter 3) that will be used to meet the measurable treatment goals; 3. a projected schedule for service delivery, including the expected frequency and duration of each treatment method; Page 8 of 49 SECTION 2

9 4. the licensure or credentials of the individuals who will furnish the prescribed services; and 5. the signature and licensure or credentials of the individual who developed the treatment plan. 1-8 Periodic Review of the Treatment Plan A. An individual identified in A of Chapter 1-5 must periodically review the client's treatment plan (at a minimum, every six months) with completion during the calendar month in which it is due. Reviews may be conducted sooner if the nature of needed services changes or there is a change in the client s condition or status as determined by the individual identified in A of Chapter 1-5 overseeing the client s treatment plan. For children in state custody, periodic reviews of the treatment plan must be conducted in accordance with the Department of Human Services review policy (i.e., at least every 90 days), or sooner if the nature of needed services changes, or if there is a change in the client s condition or status as determined by the individual identified in A of Chapter 1-5 overseeing the client s treatment plan. B. An individual identified in A of Chapter 1-5 must have sufficient face-to-face contact with the client and input from providers of services delivered during the review period in order to complete the review of progress toward the treatment goals, the appropriateness of the services being prescribed and the medical necessity of continued rehabilitative services. 1. If an individual identified in A of Chapter 1-5 provides ongoing services to the client, then the periodic review of the treatment plan conducted by this individual may not require a faceto-face contact. However, if the review does not occur during a face-to-face contact, it cannot be billed or reported. Since services provided by an individual identified in A of Chapter 1-5 should include ongoing evaluation, the periodic review of the treatment plan would be part of the service provided and may not be billed or reported under a separate service/procedure. 2. If the client s treatment plan does not include service(s) from an individual identified in A of Chapter 1-5, then an individual identified in A of Chapter 1-5 must bill or report the face-to-face contact with the client to conduct the periodic review of the treatment plan in accordance with Chapter 2-2, 3 b 4 of the Limits section. C. Treatment plan reviews shall be documented in detail in the client s record. Documentation shall include an update of progress toward established treatment goals, the appropriateness of the services being prescribed, and the medical necessity of continued rehabilitative services and the signature and licensure or credentials of the individual who conducted the periodic review of the treatment plan. If the individual identified in A of Chapter 1-5 determines during a treatment plan review that the treatment plan (e.g., problems, goals, methods, etc.) needs to be modified, then as part of the treatment plan review, an updated treatment plan also must be developed. Page 9 of 49 SECTION 2

10 1-9 Documentation A. The provider must develop and maintain sufficient written documentation for each service or session for which billing or reporting is made to support the procedure and the time billed or reported. B. See Chapter 2, Scope of Services, for documentation requirements specific to each service. As specified in Chapter 2, documentation of actual time of the service is required. However, an acceptable practice is to round to the nearest five minute interval to determine the time and duration of the service. C. The clinical record must be kept on file, and made available for state or federal review, upon request Quality Improvement PMHPs PMHPs must implement a quality assessment and performance improvement plan in accordance with the PMHP Contract. (See PMHP Contract, Article VIII, Quality Assessment and Performance Improvement, Section F., Peer Review.) Fee-For-Service Mental Health Centers These mental health centers must have a written quality improvement plan. The plan must have the means to evaluate all aspects of the organization as well as the quality and timeliness of services delivered. The plan must include an interdisciplinary quality improvement committee that has the authority to report its findings and recommendations for improvement to the agency s director. The quality improvement committee must meet a least quarterly to conduct or review quality improvement activities and make recommendations for improvement. The quality improvement plan must also include written peer review procedures to assess access and the quality and adequacy of the services being delivered. The quality improvement plans must also include written peer review procedures for determining adherence to Medicaid policy outlined in this manual and in the Medicaid Provider Manual for Targeted Case Management for the Chronically Mentally Ill, including a process for determining whether claims for Medicaid payment have been made appropriately. Peer reviews must be conducted no less than two times per year. The quality improvement committee, and any subcommittees, must maintain written documentation of quality improvement meetings and the results of peer reviews subject to review by state and federal officials Collateral Services Collateral services must be directed exclusively toward the treatment of the Medicaid individual and may be billed or reported if the following conditions are met: 1. the service is provided face-to-face to an immediate family member (for example, parent or foster parent) on behalf of the identified client and the client is not present; 2. the identified client is the focus of the session; and 3. the progress note specifies the service was a collateral service and documents how the identified client was the focus of the session. Other documentation requirements under the Record section of the applicable service also apply. Page 10 of 49 SECTION 2

11 4. If the client is receiving individual psychotherapy or family psychotherapy and the client is not present, procedure code (family psychotherapy without patient present) must be used. If the collateral service is not individual psychotherapy or family psychotherapy, the applicable service code must be used Billings (Updated 10/1/12) Multiple Same Service Contacts in a Day If the same service is provided multiple times in a day, and each service meets the minimum time requirements for billing, then each service may be billed or reported. If a service contact does not meet the minimum time requirement, it may not be billed or reported. Minimum time requirements for services are delineated in Chapter 2, Scope of Services. When multiple same services are provided in a day and each service independently meets the time specifications, each service may be billed or reported. With the exception of individual psychotherapy, multiple same services provided in a day may be billed or reported on separate lines of a claim, or the units for the separate services may be totaled and billed or reported on one line of the claim. See Chapter 2-5, Individual Psychotherapy and Individual Psychotherapy with Medical Evaluation and Management Services, Units, for instructions on billing multiple individual psychotherapy services in a day. Appropriate Billing Procedure A range of dates should not be billed or reported on a single line of a claim (e.g., the 1 st through the 30 th or 31 st as the service date). Each date of service should be billed or reported on a separate line of the claim. Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Module This NCCI module contains correct coding when two services are provided by the same servicing provider on the same day. In this module is a list of procedure code combinations. Generally, the second service is considered incident to the first service in the procedure code combination and may not be reimbursed separately. However, for some procedure code combinations, NCCI allows reimbursement of the second procedure code in the combination. In these instances, a modifier may be used on the fee-for-service claim to indicate that the two services provided on the same day by the same servicing provider were actually separate and distinct services. When both procedure codes in the combination are allowed to be reimbursed, the procedure code combination is followed by a 1 in the next column. When the second procedure code is considered incident to the first procedure code and therefore may not be reimbursed separately, the procedure code combination is followed by a 0 in the next column. When NCCI allows the second procedure in the procedure combination to be reimbursed, the 59 modifier must be included on the claim or the claim will be denied. On the CMS Medicaid page, there is an article entitled Medicare Modifier 59 Article that gives information on the use of this modifier. Medically Unnecessary Edits (MUE) Module Page 11 of 49 SECTION 2

12 The NCCI also contains a module called the Medically Unnecessary Edits (MUE) module. In this module, CMS specifies for selected procedure codes a limit on the number of units of service on a feefor-service claim that Medicaid may reimburse. CMS may update these modules quarterly. To review the modules, providers may go to the CMS website at: Click on NCCI Coding Edits, then click on Physician CCI Edits. Follow the prompts to access the files. 2. SCOPE OF SERVICES Rehabilitative mental health services are covered benefits when they are medically necessary services. Medically necessary services may include psychiatric diagnostic interview examination, mental health assessment by a non-mental health therapist, psychological testing, individual psychotherapy, individual psychotherapy with medical evaluation and management services, family psychotherapy, group psychotherapy, pharmacologic management, therapeutic behavioral services, psychosocial rehabilitative services, and peer support services as described in Chapters 2-2 through For PMHPs, rehabilitative mental health services also include 1915(b)(3) services defined in Chapter General Limitations 1. Rehabilitative services do not include: a. Services provided to inmates of public institutions or to residents of institutions for mental diseases; b. Habilitation services; c. Educational, vocational and job training services; d. Recreational and social activities; e. Room and board; and f. Services where the therapist or others during the session use coercive techniques (e.g., coercive physical restraints, including interference with body functions such as vision, breathing and movement, or noxious stimulation) to evoke an emotional response in the child such as rage or to cause the child to undergo a rebirth experience. Coercive techniques are sometimes also referred to as holding therapy, rage therapy, rage reduction therapy or rebirthing therapy. This also includes services wherein the therapist instructs and directs parents or others in the use of coercive techniques that are to be used with the child in the home or other setting outside the therapy session. 2. Medicaid adults in the Non-Traditional Medicaid Plan have the following limitations: Page 12 of 49 SECTION 2

13 a. Inpatient mental health care There is a 30-day maximum per calendar year per client for inpatient mental health care. b. Outpatient mental health services/visits There is a maximum of 30 outpatient days per client per calendar year for outpatient mental health care. Targeted case management services for the chronically mentally ill also count toward the outpatient maximum. (See provider manual entitled Utah Medicaid Provider Manual, Targeted Case Management for the ChronicallyMentally Ill.) Substitutions If without continued outpatient mental health services, the client would require psychiatric care in a hospital, the client may receive additional outpatient mental health days by forfeiting inpatient days. If the criteria for substitution are met, all outpatient mental health services, with the exception of psychosocial rehabilitative services, may be substituted at a rate of one outpatient mental health day for one inpatient day. Psychosocial rehabilitative services may be substituted at a rate of two days for each inpatient day. Example: A client has utilized the maximum outpatient mental health benefits by using ten outpatient psychosocial rehabilitative services days and 20 other outpatient mental health days. However, without continued outpatient mental health treatment, the client would require inpatient mental health care. Therefore, the client utilizes another 20 psychosocial rehabilitative services days and 15 other outpatient mental health service days. The 20 outpatient psychosocial rehabilitative services days are substituted for ten inpatient days and the 15 other outpatient mental health service days are substituted for 15 inpatient days. The client now has five inpatient mental health days available for the remainder of the calendar year. The client discontinues outpatient mental health treatment. An additional five outpatient mental health days could be used later in the year by forfeiting the remaining five inpatient days only if the client again meets the substitution criteria. Without meeting this criteria, there are no remaining outpatient mental health benefits, only the five remaining inpatient days. c. The following services are also excluded and may not be billed or reported under any of the services specified in Chapters 2-2 through 2-10 or in Chapter 3; 1) Services for conditions without manifest mental health diagnoses (i.e., conditions that do not warrant a mental health diagnosis); 2) Hypnosis, occupational or recreational therapy; and 3) Office calls in conjunction with medication management for repetitive therapeutic injections. 3. Service Coverage and Reimbursement Limitations: Information on service coverage and reimbursement limitations is not included in this provider manual. Providers must refer to Medicaid s web-based lookup tool, entitled Coverage & Reimbursement Lookup Tool, located at: The Coverage & Reimbursement Lookup Tool contains up-to-date information and allows providers to search for coverage and reimbursement information by HCPCS/CPT procedure code, date of service, and provider type. The Limits section in Chapter 2 of this manual will address other types of limits and clarifications related to the services. Page 13 of 49 SECTION 2

14 2-2 Psychiatric Diagnostic Interview Examination Psychiatric diagnostic interview examination means a face-to-face evaluation with the client to determine the existence, nature and extent of a mental illness or disorder for the purpose of identifying the client s need for mental health services, with interpretation and report. The evaluation includes a history, mental status and a disposition. It may also include communication with family or other sources and ordering and medical interpretation of laboratory or other medical diagnostic studies. In certain circumstances other informants will be seen in lieu of the client. Interactive psychiatric diagnostic interview examination- This service is typically furnished to children. It involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a client who has not yet developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language and includes physical devices, play equipment, language interpreter, or other mechanisms of non-verbal communication to aid in the examination. If it is determined services are medically necessary an individual identified in Chapter 1-5 A must develop an individualized treatment plan. (See Chapter 1-7, Treatment Plan.) A minimum duration of 30 minutes for the face-to-face component of the psychiatric diagnostic interview examination must be met; otherwise the psychiatric diagnostic interview examination may not be billed or reported. See the Limits and Unit sections below regarding appropriate use and billing or reporting of this service. Psychiatric diagnostic interview examinations may also be provided in a tele-health setting to rural clients where distance and travel time create difficulty with access. See Limits section below. Who: 1. In accordance with Chapter 1-5, B 1, a licensed mental health therapist, an individual working within the scope of his or her certificate or license or an individual exempted from licensure. 2. When evaluations are conducted only for the purpose of determining need for medication prescription, these evaluations may be conducted by: Limits: a. licensed physician and surgeon or osteopathic physician regardless of specialty; b. licensed APRN regardless of specialty; c. licensed APRN intern regardless of specialty under the supervision of a licensed APRN regardless of specialty or a licensed physician and surgeon or osteopathic physician regardless of specialty; or d. other medical practitioner licensed under state law when acting within the scope of his/her license (e.g., licensed physician assistants when practicing within their scope of practice and under the delegation of services agreement required by their practice act). Page 14 of 49 SECTION 2

15 1. In order to bill or report the psychiatric diagnostic interview examination (procedure code or 90802), the face-to-face component of the psychiatric diagnostic interview examination must have a minimum duration of 30 minutes (and the rounding rules specified for these procedure codes below in the Unit section apply). If this minimum duration is not met, the psychiatric diagnostic interview examination may not be billed or reported. Once the minimum duration has been met for the face-to-face component, then the time spent in other components of the service may also be billed or reported. 2. The psychiatric diagnostic interview examination, procedure codes and 90802, may only be billed or reported under the following circumstances: a. When a Medicaid recipient initially seeks services from the provider (or when a Medicaid recipient seeks services from the provider after a prior formal discharge from services, but not after a brief lapse in services), including: (1) evaluations requested by a court or the Utah Division of Child and Family Services (DCFS) to determine if a Medicaid-eligible child or parent has a diagnosis of a mental health disorder and to recommend a course of treatment; and (2) crisis evaluations as the initial contact to determine immediate disposition, level of care needed (e.g., hospitalization versus outpatient services), etc. If the individual is then referred for further services, this evaluation does not preclude provision of a subsequent psychiatric diagnostic interview examination. Each evaluation may be billed or reported under procedure code or 90802; b. When the Department of Workforce Services (DWS) or the Department of Health requests a mental health evaluation or re-evaluation to determine mental disability, or when other agencies request mental health evaluations, and the Medicaid recipient is not an existing client; c. When a client requires an evaluation by a qualified physician or other prescriber to determine need for medication prescription; d. In accordance with Federal managed care regulations, when a PMHP enrollee requests a second opinion and another evaluation is required to provide the second opinion; or e. When there is a change in provider agency (then the situation in a. above applies). 3. In some situations, it may be necessary for an individual identified in A of Chapter 1-5 to perform additional face-to-face evaluation with an existing client. These additional evaluations may not be billed or reported under procedure code or Additional evaluation enhances the psychiatric diagnostic interview examination (upon which services are being provided). a. When an individual identified in A of Chapter 1-5 provides services to the client, evaluations for the following purposes may not be billed or reported under a separate service/procedure code but are part of the service in which they occurred (e.g., individual or family psychotherapy, therapeutic behavioral services, etc.): (1) the periodic review of the treatment plan with the client, including evaluation updates/reviews of the treatment plan after any brief lapses in services (See Chapter 1-8); or Page 15 of 49 SECTION 2

16 (2) crisis situations with a client, unless the situation in b (2) below applies. b. Procedure code G0409 must be billed or reported in the following situations where additional face-to-face evaluation is necessary: (1) when a client is referred to a different program or level of care within the same agency (e.g., a transfer to a residential treatment program from outpatient services) and the receiving program performs further face-to-face evaluation with the client; (2) when there is a crisis situation and an individual identified in A of Chapter 1-5 is one of the client s service providers but the individual is providing the crisis evaluation in a separate role of crisis worker or crisis evaluator and the evaluation is not provided during a regular service/session; (3) when the Department of Workforce Services (DWS) or the Department of Health requests a mental health evaluation or re-evaluation to determine mental disability, or when other agencies request a mental health evaluation and face-to-face contact with the client is necessary to meet the request. (4) when the client is not receiving services from an individual in A of Chapter 1-5 and therefore the situation in 3 a above does not apply, and: (a) an individual in A of Chapter 1-5 conducts the periodic review of the treatment plan with the client, including evaluation updates/reviews of the treatment plan after any brief lapses in services (See Chapter 1-8); or (b) there is a crisis situation and an individual in A of Chapter 1-5 performs a crisis evaluation; or (5) during other situations not addressed in 2 or 3 above when additional evaluation is necessary and cannot be provided as part of another service (e.g., individual psychotherapy). 4. Evaluations requested by a court of the Utah Department of Human Services, Division of Child and Family Services, solely for the purpose of determining if a parent is able to parent and should therefore be granted custody or visitation rights, or whether the child should be in some other custodial arrangement are not billable or reportable to Medicaid under any service/procedure code. 5. Psychiatric diagnostic interview examinations provided in a tele-health setting are limited to clients residing in rural areas of Utah and are limited to evaluations conducted by a qualified prescriber to determine need for medication prescription. 6. When a psychiatric diagnostic interview examination is provided in a tele-health setting, only this subcontracted service may be billed or reported. The time spent by a mental health targeted case manager or other mental health professional to assist the client during the service provided in the telehealth setting may not also be billed or reported. Record: Documentation must include: 1. date and actual time of the service (time may be rounded to the nearest five minute interval); 2. duration of the service; Page 16 of 49 SECTION 2

17 3. setting in which the service was rendered; 4. specific service rendered; 5. For psychiatric diagnostic interview examinations (billed or reported under procedure code or 90802), a report of findings that includes: a. history, symptomotology and mental status (mental status report may be based on formal assessment or on observations from the evaluation process); and b. disposition, including diagnosis(es), recommended mental health services, and other recommended services as appropriate; or 6. For additional evaluations billed or reported in accordance with 3 b of the Limits section above, updates regarding the items contained in 5 a and b; and 7. signature and licensure or credentials of individual who rendered the service. Unit: Psychiatric Diagnostic Interview Examination - per 15 minutes Interactive Psychiatric Diagnostic Interview Examination - per 15 minutes The units of service must be billed or reported according to the date that the service component was delivered. When billing or reporting these procedure codes, follow these rounding rules for converting actual time to the specified number of units: Less than 30 minutes for the face-to-face component equals 0 units (Once the minimum duration has been met for the face-to-face component, then the time spent in other components may also be billed or reported.) 30 minutes through 37 minutes of service equals 2 units; 38 minutes through 52 minutes of service equals 3 units; 53 minutes through 67 minutes of service equals 4 units; 68 minutes through 82 minutes of service equals 5 units; 83 minutes through 97 minutes of service equals 6 units; 98 minutes through 112 minutes of service equals 7 units; and 113 minutes through 127 minutes of service equals 8 units, etc. G0409 Social work and psychological services (i.e., mental health therapist services) directly relating to and/or furthering the client s rehabilitation goals per 15 minutes Page 17 of 49 SECTION 2

18 When billing or reporting this procedure code in accordance with #3 of the Limits section above, follow these rounding rules for converting actual time to the specified number of units: Less than 8 minutes equals 0 units; 8 minutes through 22 minutes of service equals 1 unit; 23 minutes through 37 minutes of service equals 2 units; 38 minutes through 52 minutes of service equals 3 units; 53 minutes through 67 minutes of service equals 4 units; 68 minutes through 82 minutes of service equals 5 units; 83 minutes through 97 minutes of service equals 6 units; 98 minutes through 112 minutes of service equals 7 units; and 113 minutes through 127 minutes of service equals 8 units, etc. 2-3 Mental Health Assessment by a Non-Mental Health Therapist Mental health assessment by a non-mental health therapist means individuals listed below participating as part of a multi-disciplinary team in the psychiatric diagnostic interview examination process and in the periodic review of the treatment plan by gathering psychosocial data, including basic historical, social, functional, psychiatric, developmental, or other information, through face-to-face contacts with the client. Additional psycho-social information may be collected through face-to-face or telephonic interviews with family/guardians or other informants as necessary. Also see #1 in Limits section below. Who: 1. The following individuals when under the supervision of a licensed mental health therapist identified in Chapter 1-5, A 1: a. licensed social service worker or individual working toward licensure as a social service worker; b. licensed registered nurse; or c. licensed practical nurse. 2. Registered nursing student enrolled in an education/degree program exempted from licensure and under supervision in accordance with Chapter 1-5, B 3. Although one of these individuals may assist in the evaluation or the periodic review of the treatment plan process by gathering the psychosocial data as directed by the supervisor, under state law, an individual identified in the Who section of Chapter 2-2 must conduct the psychiatric diagnostic interview examination or the periodic review of the treatment plan. (See Chapter 1-8, Periodic Review of the Treatment Plan.) These individuals may also participate as part of the multidisciplinary team in the development of the treatment plan, but they may not independently diagnose Page 18 of 49 SECTION 2

19 Limits: or prescribe treatment. Individuals identified in the Who section of Chapter 2-2, based on their evaluation of the client, must diagnose and prescribe treatment. This service is meant to accompany the psychiatric diagnostic interview examination (see Chapter 2-2) or the periodic review of the treatment plan (see Chapters 1-8 and 2-4). Therefore, it should be billed or reported only if a psychiatric diagnostic interview examination or a review of the treatment plan is also provided. However, if a psychiatric diagnostic interview examination or a periodic review of the treatment plan is not conducted after this assessment is performed, this assessment may be billed or reported if: (1) all of the documentation requirements in the Record section are met; and (2) the reason for non-completion of the psychiatric diagnostic interview examination or the treatment plan review is documented. Record: Documentation must include: 1. date and actual time of the service (time may be rounded to the nearest five minute interval); 2. duration of the service; 3. setting in which the service was rendered; 4. specific service rendered; 5. summary of psychosocial findings; and 6. signature and licensure or credentials of individual who rendered the service. Unit: H Mental Health Assessment by a Non-Mental Health Therapist per 15 minutes When billing or reporting this procedure code, follow these rounding rules for converting actual time to the specified number of units: Less than 8 minutes equals 0 units; 8 minutes through 22 minutes of service equals 1 unit; 23 minutes through 37 minutes of service equals 2 units; 38 minutes through 52 minutes of service equals 3 units; 53 minutes through 67 minutes of service equals 4 units; 68 minutes through 82 minutes of service equals 5 units; 83 minutes through 97 minutes of service equals 6 units; 98 minutes through 112 minutes of service equals 7 units; and 113 minutes through 127 minutes of service equals 8 units, etc. Page 19 of 49 SECTION 2

20 2-4 Psychological Testing Psychological testing means a face-to-face evaluation to determine the existence, nature and extent of a mental illness or disorder using psychological tests appropriate to the client s needs, including psychometric, diagnostic, projective, or standardized IQ tests, with interpretation and report. Who: 1. licensed physician and surgeon, or osteopathic physician engaged in the practice of mental health therapy; 2. licensed psychologist qualified to engage in the practice of mental health therapy; 3. certified psychology resident under the supervision of a licensed psychologist qualified to engage in the practice of mental health therapy; 4. psychology student enrolled in a predoctoral education/degree program exempted from licensure and under supervision in accordance with Chapter 1-5, A 3 a; or 5. an individual exempted from licensure in accordance with Chapter 1-5, A 3 b employed as a psychologist by a state, county or municipal agency or other political subdivision of the state prior to July 1, 1981, and who subsequently has maintained employment as a psychologist in the same state, county, or municipal agency or other political subdivision while engaged in the performance of his/her official duties for that agency or political subdivision. [See Title (2)(h).] Limits: There are coverage and reimbursement limitations on neuropsychological testing, procedure codes and Refer to Chapter 2-1, General Limitations, #3, regarding the procedure for accessing information on Medicaid coverage and reimbursement limitations. Record: Documentation must include: 1. date(s) and actual time(s) of testing (time may be rounded to the nearest five minute interval); 2. duration of the testing; 3. setting in which the testing was rendered; 4. specific service rendered; 5. signature and licensure or credentials of individual who rendered the service; and 6. written test reports which include: a. brief history b. tests administered; c. test scores; d. evaluation of test results; e. current functioning of the examinee; f. diagnoses; g. prognosis; and Page 20 of 49 SECTION 2

21 Unit: h. specific treatment recommendations for mental health services, and other recommended services as appropriate Psychological Testing - includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS-R, Rorschach, MMPI, with interpretation and report - per hour Assessment of Aphasia - includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading spelling, writing, e.g., Boston Diagnostic Aphasia Examination, with interpretation and report - per hour Developmental Testing: limited - e.g., Developmental Screening Test ll, Early Language Milestone Screen, with interpretation and report - per hour Developmental Testing: extended -includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, e.g., Bayley Scales of Infant Development, with interpretation and report - per hour Neurobehavioral Status Exam - Clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning, with interpretation and report - per hour Neuropsychological Testing Battery - e.g., Halstead-Reitan, Luria, WAIS-R, with interpretation and report - per hour. When billing or reporting these procedure codes, follow these rounding rules for converting actual time to the specified number of units: Less than 30 minutes equals 0 units; 30 minutes through 89 minutes of service equals 1 unit; 90 minutes through 149 minutes of service equals 2 units; 150 minutes through 209 minutes of service equals 3 units; and 210 minutes through 269 minutes of service equals 4 units; etc. 2-5 Individual Psychotherapy and Individual Psychotherapy with Medical Evaluation and Management Services Individual psychotherapy means face-to-face interventions with an individual client. Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the client and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development so that the client may be restored to his/her best possible functional level. Page 21 of 49 SECTION 2