Alcohol and Drug Rehabilitation Providers

Transcription

1 June 2009 Provider Bulletin Number 942 Alcohol and Drug Rehabilitation Providers New Modifier and s for Substance Abuse Services Effective with dates of service on and after July 1, 2009, eligible substance abuse providers offering services to eligible Medicaid beneficiaries will have new service codes. For rehabilitation outpatient and assessment-related substance abuse service providers, these include the following codes: H0038 and H0038 HQ H0007 Delivery of services through telemedicine using a GT modifier: H0001 GT, H0004 GT, H0005 GT, H0006 GT, H0007 GT, H0038 GT, H0038 HQ GT Note: For guidelines concerning the use of telemedicine, please refer to Section 2720 of the General Benefits Provider Manual. These changes will be available for eligible providers and beneficiaries in both the community-based managed care Pre-paid Inpatient Health Plan (PIHP) program and the fee for service program. Additional details will be provided from the PIHP contractor, ValueOptions-KS. For updated information, reference the Non-PIHP Alcohol and Substance Abuse Community Based Services Provider Manual. If you have any questions or need additional information, please contact Kim Brown with the State of Kansas Department of Social and Rehabilitation Services (SRS), Disability and Behavioral Health Services, at or Kim.Brown@srs.ks.gov. Information about the KHPA Medical Plans as well as provider manuals and other publications are available at For the changes resulting from this provider bulletin, please view the General Benefits Provider Manual, Section 2720, page 2-57, and the Non-PIHP Alcohol and Substance Abuse Community Based Services Provider Manual, Section 8400, pages 8-4 through 8-7 and the Appendix section, page A-1. If you have any questions, please contact Customer Service at (in-state providers) or between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the KHPA Medical Plans. Page 1 of 7

2 2720. TELEMEDICINE Updated 06/09 Telemedicine is the use of communication equipment to link health care practitioners and patients in different locations. This technology is used by health care providers for many reasons, including increased cost efficiency, reduced transportation expenses, improved patient access to specialists and mental health providers, improved quality of care, and better communication among providers. Consultations, office visits, individual psychotherapy, and pharmacological management services may be reimbursed when provided via telecommunication technology. The consulting or expert provider must bill the codes listed below using the GT modifier and will be reimbursed at the same rate as face-to-face services. The originating site, with the beneficiary present, may bill code Q GT 90804GT GT GT GT 99211GT GT 99241GT GT 99251GT GT 99261GT GT 99271GT GT H0001GT H0004GT H0005GT H0006GT H0007GT H0038GT H0038HQGT LIMITATIONS The patient (beneficiary) must be present at the originating site. , telephone and facsimile transmissions are not covered as telemedicine services. Documentation requirements are the same as face-to-face services per Section 2710, General Therapy Guidelines and Requirements. GENERAL BENEFITS PROVIDER MANUAL 2-57

3 8400. MEDICAID Updated 06/09 Enrolled alcohol and substance abuse providers must be licensed by Social and Rehabilitation Services Addiction and Prevention Services (AAPS). Potential providers must complete the following steps, which will be verified in writing by AAPS prior to the enrollment application with the fiscal agent: Complete a computer questionnaire and security forms provided by AAPS to ensure there is sufficient hardware, software, and Internet access to meet the electronic data collection and reporting requirements Enter into a contract that will provide ongoing KCPC software computer support Receive authorization from AAPS to download and install the KCPC system Provide evidence that clinical staff have attended an AAPS approved KCPC training After completion of the above steps, AAPS will issue a letter of approval and the potential provider will complete an enrollment application with the fiscal agent. Upon completion of the enrollment application with the fiscal agent, the potential provider will contact AAPS to ensure the process for electronic data collection has occurred. Only services described herein, approved by the Regional Alcohol and Drug Assessment Center (RADAC) determined to be medically necessary by ValueOptions-KS and provided by approved center staff in the manner described and in accordance with the beneficiary s individualized treatment plan, are reimbursable for alcohol and substance abuse community based services. General Charting Documentation Guidelines All clinical activity delivered in the course of treatment must be outlined in the individualized treatment plan with specific goals based on the assessment of medical necessity for treatment. This treatment plan is reviewed and updated regularly according to guidelines based on the beneficiary s assigned level of care. Documentation must show progress, be legible, and include, at a minimum, the following: Start and stop time Type of clinical activity Major issues covered from the treatment plan goals Complete date to include month, day, and year Staff providing the service and staff signature including credentials Progress notes related to the treatment plan goals 8-4

4 8400. MEDICAID Updated 06/09 Outpatient Outpatient counseling (behavioral health counseling and therapy or group counseling by a clinician) provides nonresidential alcohol and substance abuse treatment in an individual and/or group setting. Group outpatient counseling consists of counseling delivered in a group setting to two or more beneficiaries. Treatment must be based on an individualized treatment plan which is based on the assessment. This initial treatment plan must be completed within 30 days of the beneficiary s admittance into treatment and must be updated every 90 days. The provider must document every session. These outpatient services are limited to nine hours of scheduled counseling services each seven-day period. Peer support (PS) services are beneficiary centered services with a rehabilitation and recovery focus. These services are designed to promote skills to cope with and manage substance abuse symptoms while facilitating the use of natural resources and the enhancement of community living skills. Activities included must be intended to achieve the identified goals or objectives as set forth in the beneficiary s individualized treatment plan. The structured, scheduled activities provided by this service emphasize the opportunity for beneficiaries to support each other in the restoration and expansion of the skills and strategies necessary to move forward in recovery. PS is a face-to-face intervention with the beneficiary present. Services may be provided individually or in a group setting. The majority of PS contacts must occur in outpatient treatment centers and/or community locations where the beneficiary lives, works, attends school, and/or socializes. Provider must follow AAPS Peer Support Services Policy to provide these services. PS services will help the beneficiary to develop a network for information and support from others who have been through similar experiences. To bill for PS, submit the following codes: H0038, PS Individual H0038HQ, PS Group Services are limited to no more than 12 units a day for each beneficiary. Crisis intervention (CI) services are provided to a beneficiary who is experiencing a substance abuse crisis. CI is designed to interrupt and/or ameliorate a crisis experience, including a preliminary screening, immediate crisis resolution and de-escalation, and referral and linkage to appropriate community services to avoid more restrictive levels of treatment. The goals of CI are symptom reduction, stabilization, and restoration to a previous level of functioning. All activities must occur within the context of a potential or actual substance abuse crisis. CI is a face-to-face or telephonic intervention and may occur in a variety of locations, including emergency room or clinic setting, in addition to other community locations where the beneficiary lives, works, attends school, and/or socializes. This service may include the following components: 8-5

5 8400. MEDICAID Updated 06/09 A preliminary screening of risk, mental status, and medical stability and the need for further evaluation for other services Note: This includes contact with the beneficiary, family members or other collateral sources (such as caregiver or school personnel) with pertinent information for the purpose of a preliminary screening and/or referral to alternative services at an appropriate level. Short-term CI, including crisis resolution, debriefing, and follow-up with the beneficiary, and as necessary, with the beneficiary s caretaker and/or family members Consultation with a physician or with other providers to assist with the beneficiary s specific crisis Providers must follow AAPS Crisis Intervention Policy to provide this service. To bill for CI, submit code H0007. Case Management Case management means a one-on-one goal directed service for the substance abuse/dependent beneficiary through which the beneficiary is assisted in obtaining access to needed family, legal, medical, employment, educational, psychiatric, and other services. This service must be part of the treatment plan developed and approved by the RADAC determined medically necessary by ValueOption-KS. Case management services must be delivered by the program based upon the results of KCPC. The worker providing the service must at a minimum have: A high school degree with documented training in federal confidentiality guidelines as they relate to substance abuse At least two years experience working with substance abuse programs Supervision by an AAPS credentialed substance abuse counselor Intensive Outpatient Intensive outpatient treatment (intensive outpatient) means treatment activities based on the individualized treatment plan where services are offered in regularly scheduled sessions throughout the week by approved center staff. Beneficiaries participate in structured therapeutic activities that may include alcohol and/or other substance abuse educational didactic groups, group counseling, and individual counseling. Intensive outpatient treatment consists of participating in services for a minimum of nine hours (for adults) and six hours (for those under 18) each in a seven-day period. These minimum requirements must be met to be reimbursed for this level of service. The national standard for adults is for a treatment program to operate at least three hours/day and at least three days/week (for those under 18, at least two hours/day and at least three days/week) and This service must consist of services delivered at a minimum of three hours a day at least three days each week. These services must be based on an individualized treatment plan including assessment, counseling, crisis intervention, and activity therapies or education. In Kansas, it is only acceptable to bill for this service daily if the beneficiary participates in a minimum of nine hours (or six hours if under 18 years of age) of service in a seven-day period. 8-6

6 8400. MEDICAID Updated 06/09 Telemedicine Telemedicine is the use of communication equipment to link healthcare providers and patients in different locations. Healthcare providers use this technology for many reasons, including increased cost efficiency, reduced transportation expenses, improved patient access to specialist and substance abuse providers, improved quality of care, and better communication among providers. Substance abuse outpatient, assessment and case management services may be reimbursed when provided through telecommunication technology (excluding intensive outpatient treatment). The substance abuse treatment provider must bill the codes listed below using the GT modifier (through interactive audio and video telecommunication systems) and are reimbursed at the same rate as face-to-face services. The originating site, with the beneficiary present, may bill code Q3014. H0001 GT, H0004 GT, H0005 GT, H0006 GT, H0007 GT, H0038 GT, H0038 HQ GT 8-7

7 APPENDIX Updated 06/09 CODES The following Current Procedureal Technology (CPT ) codes represent an all inclusive list of alcohol and substance abuse community based services billable for beneficiaries not assigned to PIHP. Procedures not listed here are considered noncovered. ASSESSMENT AND REFERRAL (KCPC SCREENING INSTRUMENT) H0001 One unit = one assessment OUTPATIENT INDIVIDUAL H0004 OUTPATIENT GROUP H0005 SUBSTANCE ABUSE CASE MANAGEMENT H0006 SUBSTANCE ABUSE CRISIS INTERVENTION H0007 INTENSIVE OUTPATIENT H0015 One unit = one day PEER SUPPORT INDIVIDUAL H0038 PEER SUPPORT GROUP H0038 HQ All above codes may be reimbursed (excluding H0015) with GT modifier for telemedicine. APPENDIX A-1