Children s Mental Health Clinical Consultations

Transcription

1 Children s Mental Health Consultations Policy Number: SC17P0061A Effective Date: May 1, 2018 Last Updated: PAYMENT POLICY HISTORY VERSION DATE ACTION / DESCRIPTION Version 1 5/1/2018 The Children s Mental Health Consultations policy is implemented by UCare. Table of Contents Page PAYMENT POLICY HISTORY... 1 DEFINITIONS... 5 PAYMENT AND BILLING INFORMATON... 8 Covered Services... 8 Non-Covered Services... 8 Payment Decreases and Increases Impacting Mental Health Services... 9 Billing Guidelines Time Based Services RELATED PAYMENT POLICY DOCUMENTATION REFERENCES AND SOURCE DOCUMENTS Copyright 2013, Proprietary Information of UCare Page 1 of 14

2 Payment Policies assist in administering payment for UCare benefits under UCare s health benefit plans. Payment Policies are intended to serve only as a general reference resource regarding UCare s administration of health benefits and are not intended to address all issues related to payment for health care services provided to UCare members. In particular, when submitting claims, all providers must first identify member eligibility, federal and state legislation or regulatory guidance regarding claims submission, UCare provider participation agreement contract terms, and the member-specific Evidence of Coverage (EOC) or other benefit document. In the event of a conflict, these sources supersede the Payment Policies. Payment Policies are provided for informational purposes and do not constitute coding or compliance advice. Providers are responsible for submission of accurate and compliant claims. In addition to Payment Policies, UCare also uses tools developed by third parties, such as the Current Procedural Terminology (CPT *), InterQual guidelines, Centers for Medicare and Medicaid Services (CMS), the Minnesota Department of Human Services (DHS), or other coding guidelines, to assist in administering health benefits. References to CPT or other sources in UCare Payment Policies are for definitional purposes only and do not imply any right to payment. Other UCare Policies and Coverage Determination Guidelines may also apply. UCare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary and to administer payments in a manner other than as described by UCare Payment Policies when necessitated by operational considerations. *CPT is a registered trademark of the American Medical Association Copyright 2013, Proprietary Information of UCare Page 2 of 14

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4 PAYMENT POLICY OVERVIEW PRODUCT SUMMARY This Policy applies to the following UCare products: UCare Connect (Special Needs Basic Care SNBC) Prepaid Medical Assistance Program (PMAP) MinnesotaCare PROVIDER SUMMARY The following providers are eligible to furnish Children s Mental Health Care Consultations: nurse specialist in mental health (CNS) Licensed independent clinical social worker (LICSW) Licensed marriage and family therapist (LMFT) Licensed professional clinical counselor (LPCC) Licensed psychologist (LP) Psychiatric nurse practitioner (NP) Psychiatrist or osteopathic physician Tribal mental health professional Mental health practitioners working as a clinical trainees POLICY STATEMENT This Policy outlines the payment and billing guidelines associated with Children s Mental Health Consultations. PATIENT ELIGIBILITY CRITERIA In order for services to be covered by UCare the patient must: Be actively enrolled in a UCare Connect, PMAP, or MinnesotaCare product; Be twenty-one years (21) of age or younger; and Have a diagnosis of mental illness determined by a diagnostic assessment. Copyright 2013, Proprietary Information of UCare Page 4 of 14

5 DEFINITIONS TERM Complex Needs Diagnostic Assessment Mental Health Care Consultation NARRATIVE DESCRIPTION Means needs caused by acuity of psychotic disorder; cognitive or neurocognitive impairment; a need to consider past diagnoses and determine their current applicability; co-occurring substance abuse use disorder; or disruptive or changing environments, communication barriers, or cultural considerations as documented in the assessment. Means functional face-to-face evaluation resulting in a complete written assessment that includes clinical considerations and severity of the client's general physical, developmental, family, social, psychiatric, and psychological history and current condition. The Diagnostic Assessment will also note strengths, vulnerabilities, and needed mental health services. Means communication between a treating mental health professional and other providers or educators to discuss patient care focusing on: Issues related to the patient's symptoms Strategies for effective engagement, care and intervention needs Treatment expectations across service settings service components provided to the patient and family/guardian Individual Treatment Plan (ITP) Notification Prior Authorization Means the person-centered process that focuses on developing a written plan that defines the course of treatment for the patient. The plan is focused on collaboratively determining real-life outcomes with a patient and developing a strategy to achieve those outcomes. The plan establishes goals, measurable objectives, target dates for achieving specific goals, identifies key participants in the process, and the responsible party for each treatment component. In addition, the plan outlines the recommended services based on the patient s diagnostic assessment and other patient specific data needed to aid the patient in their recovery and enhance resiliency. An individual treatment plan should be completed before mental health service delivery begins. Means the process of informing UCare or their delegates of a specific medical treatment or service prior to billing for certain services. Services that require notification are not subject to review for medical necessity, but must be medically necessary and covered within the member s benefit set. If claims are submitted to UCare and no notification has been received from the provider the claim will be denied. Means an approval by UCare or their delegates prior to the delivery of a specific service or treatment. Prior authorization requests require a clinical review by Copyright 2013, Proprietary Information of UCare Page 5 of 14

6 DEFINITIONS TERM NARRATIVE DESCRIPTION, appropriate professionals to determine if the service or treatment is medically necessary. UCare requires certain services to be authorized before services begin. Services provided without an authorization will be denied. MODIFIERS The modifiers listed below are not intended to be a comprehensive list of all modifiers. Instead, the modifiers that are listed are those that must be appended to the CPT / HCPCS codes listed below. Based on the service(s) provided and the circumstances surrounding those services it may, based on correct coding, be appropriate to append an additional modifier(s) to the CPT / HCPCS code. When a service requires multiple modifiers the modifiers must be submitted in the order listed below. If it is necessary to add additional modifiers they should be added after the modifiers listed below. MODIFIER HN U4 U8 U9 UB UC NARRATIVE DESCRIPTION For purposes of this policy, the HN modifier indicates services were furnished by a Mental Health Practitioner or when licensing and supervision requirements are met Care Consultation non-face-to-face Care Consultation, face-to-face 5 10 minutes care Consultation, face-to-face minutes Care Consultation, face-to-face minutes Care Consultation, face-to-face 31 minutes and above Copyright 2013, Proprietary Information of UCare Page 6 of 14

7 CPT / HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION U8 Care Consultation, face-to-face 5 10 minutes U8, HN Care Consultation, face-to-face 5 10 minutes, furnished by a U8, U4 Care Consultation, non-face-to-face, 5 10 minutes U8, U4, HN Care Consultation, non-face-to-face, 5 10 minutes, furnished by a U9 care Consultation, face-to-face minutes U9, HN care Consultation, face-to-face minutes, furnished by a U9, U4 care Consultation, non-face-to-face minutes U9, U4, HN care Consultation, non-face-to-face minutes, furnished by a UB Care Consultation, face-to-face minutes UB, HN Care Consultation, face-to-face minutes, furnished by a UB, U4 Care Consultation, non-face-to-face minutes UB, U4, HN Care Consultation, non-face-to-face minutes, furnished by a UC Care Consultation, face-to-face 31 minutes and above UC, HN Care Consultation, face-to-face 31 minutes and above furnished by a UC, U4 Care Consultation, non-face-to-face 31 minutes and above UC, U4, HN Care Consultation, non-face-to-face 31 minutes and above, furnished by a Copyright 2013, Proprietary Information of UCare Page 7 of 14

8 PAYMENT AND BILLING INFORMATON Covered Services MHCP covers mental health clinical care consultation between the treating mental health professional and another provider or educator. Examples of appropriate providers and educators who may receive a consultation include the following: Home health care agencies Child care providers Children s mental health case managers Educators Probation agents Adoption or guardianship workers Guardians ad litem Child protection workers Pediatricians Nurses After-school program staff Mentors Services may be furnished face-to-face, via telemedicine, or by telephone. Non-Covered Services Mental Health Care Consultation does not include the following: Communication between the treating mental health professional and a person under the clinical supervision of the treating mental health professional Written communication between providers Reporting, charting and record keeping (These activities are the responsibility of the provider) Mental health services not related to the patient s diagnosis or treatment for mental illness Communication provided during the performance of any of the following mental health services: o Mental health case management o In-reach services o Youth ACT o Intensive treatment services in foster care. Copyright 2013, Proprietary Information of UCare Page 8 of 14

9 Payment Decreases and Increases Impacting Mental Health Services Based on MHCP guidelines when certain mental services are furnished by a Master s level provider a twenty percent (20%) reduction is applied to the allowed amount. Master s level providers are: Nurse Specialist (CNS-MH) Licensed Independent Social Worker (LICSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Counselor (LPCC) Licensed Psychologist (LP) Master s Level Psychiatric Nurse Practitioner Master s Level enrolled provider UCare follows MHCP guidelines when applying Master s level provider reductions to eligible mental health services. Impacted services are identified by indicator (a) in the DHS MH Procedure CPT or HCPC Codes and Rates Chart. A link to this chart is available in the References and Sources section of this Policy. Master s level provider reductions are not applied to mental health services when they are furnished in a Community Mental Health Center (CMHC). In addition to the Master s level provider reduction, UCare also applies a 23.7% increase to mental health services identified with a b in the DHS MH Procedure CPT or HCPC Codes and Rates Chart. A link to this chart is available in the References and Sources section of this Policy. This increase is applied to behavioral health services when performed by: Psychiatrists; Advance Practice Nurses; o Nurse Specialist o Nurse Practitioner Community Mental Health Centers; Mental health clinics and centers certified under Rule 29 and designated by the Minnesota Department of Mental Health as an essential community provider; Hospital outpatient psychiatric departments designated by the Minnesota Department of Mental Health as an essential community provider; and Children s Therapeutic Services and Supports (CTSS) providers for services identified as CTSS in the DHS mental health procedure CPT or HCPCs codes and rates chart. UCare will utilize the above-referenced MHCP list to determine whether the decrease to Master s level providers or a Mental Health Practitioner working as a clinical trainee should be applied, and/or Copyright 2013, Proprietary Information of UCare Page 9 of 14

10 determine if the 23.7% legislative increase will be applied to behavioral health services. If there is a discrepancy between how DHS adjudicates claims and the chart published in the MHCP provider manual, UCare will adjudicate claims based on the chart published by DHS. When DHS updates the published chart, UCare will update payment requirements within forty (40) business days of receipt of the change. Claims previously paid will not be adjusted. Additional information regarding UCare fee schedule updates can be found in the UCare Provider Manual, (Section 10-20, Fee Schedule Updates). The grid below identifies whether the Master s level provider reduction and/or 23.7% increase applies to service(s) associated with Children s Mental Health Care Consultations. CPT /HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION U8 Care 5 10 minutes U8, HN Care 5 10 minutes furnished by a U8, U4 Care 5 10 minutes U8, U4, HN Care 5 10 minutes furnished by a UNIT OF SERVICE MASTER S LEVEL REDUCTION DOES 23.7% INCREASE PROVIDERS ELIGIBLE TO PERFORM SERVICE CC Psychiatrist CC Psychiatrist Copyright 2013, Proprietary Information of UCare Page 10 of 14

11 CPT /HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION U9 care minutes U9, HN care minutes, furnished by a U9, U4 care minutes U9, U4, HN care minutes, furnished by a UB Care minutes UB, HN Care minutes, furnished by a UNIT OF SERVICE MASTER S LEVEL REDUCTION PROVIDER PAYMENT POLICY DOES 23.7% INCREASE PROVIDERS ELIGIBLE TO PERFORM SERVICE CC Psychiatrist CC Psychiatrist CC Psychiatrist Copyright 2013, Proprietary Information of UCare Page 11 of 14

12 CPT /HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION UB, U4 Care minutes UB, U4, HN Care minutes, furnished by a UC Care 31 minutes and above UC, HN Care 31 minutes and above furnished by a UC, U4 Care 31 minutes and above UC, U4, HN Care 31 minutes and above, furnished by a UNIT OF SERVICE and above 31 and above 31 and above 31 and above MASTER S LEVEL REDUCTION PROVIDER PAYMENT POLICY DOES 23.7% INCREASE PROVIDERS ELIGIBLE TO PERFORM SERVICE CC Psychiatrist CC Psychiatrist CC Psychiatrist Copyright 2013, Proprietary Information of UCare Page 12 of 14

13 CPT /HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION UNIT OF SERVICE MASTER S LEVEL REDUCTION DOES 23.7% INCREASE PROVIDERS ELIGIBLE TO PERFORM SERVICE In the event that other government-based adjustments are required, UCare will implement those changes that apply to managed care organizations. The impact will be reflected in the providers final payment. When DHS updates the published list of impacted services / fee schedule, UCare will update payment requirements within forty (40) business days of receipt of the change. Claims previously paid will not be adjusted. Additional information regarding UCare fee schedule updates can be found in the UCare Provider Manual (Section 10-20, Fee Schedule Updates). Billing Guidelines Services should be submitted using the 837-P MN-ITS format or the electronic equivalent. Submit one claim line per day for each service (Add up all the minutes of service provided for face-to-face or non-face-to-face services for each client for that day and submit a single claim regardless of the number of consultations) Two mental health professionals treating the same patient may consult. When this situation occurs the providers will need to split the time into two billable amounts comprising the total amount of time spent in consultation. Mental health clinical care consultation may be done by telephone or face-to-face Enter the treating provider NPI number on each claim line Children s Mental Health Case Management services are outpatient services and cannot be billed under CTSS. Time Based Services When billing for services that include time as part of their definition, follow HCPCS and CPT guidelines to determine the appropriate unit(s) of service to report. Based on current guidelines, providers must spend more than half the time of a time-based code performing the service to report the code. If the time spent results in more than one and one half times the defined value of the code, and no additional time increment code exists, round up to the next whole number. Outlined below are the billable units of service based on whether the description of the service includes the unit of measurement of 15 minutes or 60 minutes: Copyright 2013, Proprietary Information of UCare Page 13 of 14

14 MINUTES BILLABABLE UNITS Fifteen (15) Minute Increments 0 7 minutes 0 (no billable unit of service) 8 15 minutes 1 (unit of billable service) Sixty (60) Minute Increments 0 30 minutes 0 (no billable unit of service) minutes 1 (unit of billable service) PRIOR AUTHORIZATION, NOTIFICATION AND THRESHOLD LIMITS UCare s prior authorization and/or notification requirements and threshold limits may be updated from time to time. The most current information can be found here. RELATED PAYMENT POLICY DOCUMENTATION REFERENCES TO OTHER PAYMENT POLICY DOCUMENTATION THAT MAY BE RELEVANT TO THIS POLICY POLICY NUMBER SC14P0004A1 POLICY DESCRIPTION AND LINK Diagnostic Assessments and Updates REFERENCES AND SOURCE DOCUMENTS LINKS TO CMS, MHP, MINNESOTA STATUTE AND OTHER RELEVANT DOCUMENTS USED TO CREATE THIS POLICY DHS MH Procedure CPT or HCPCS Codes and Rates Chart MHCP Provider Manual, Mental Health Services, Children s Mental Health Care Consultations, Minnesota Rule Medical Assistance Coverage Requirements for Outpatient Mental Health Services Minnesota Statutes 256B.0625, sub.62 Covered Services, Mental health clinical care consultation Copyright 2013, Proprietary Information of UCare Page 14 of 14