Medicaid Child/Adolescent MH Services Benefit Plan Effective January 1, 2019 Updated January 1, 2019

Transcription

1 Assessment/Intake N/A Codes: (GT); (DJ); TK (Interactive complexity add-on code) 4 visits per year per consumer. 1 unit per episode. Prior authorization is required beyond 4 visits. Visits do not count against unmanaged limits. Diagnostic Assessment: T1023 T1023 (GT) 4 visits per year per consumer. Prior authorization is required. Visits do not count against unmanaged limits. N/A E/M Assessment Codes: (GT) E/M Codes have unlimited benefits. No prior approval or authorization is required. N/A E/M Established Patient Codes: E/M Codes have unlimited benefits. No prior approval or authorization is required. N/A (GT) Electroconvulsive Therapy (ECT): Six (6) unmanaged ECT sessions per episode of care. Prior authorization is required before the seventh (7th) and subsequent ECT sessions per episode of care. Completion of Electroconvulsive Therapy (ECT) Checklist 1

2 Eye Movement Desensitization and Reprocessing (EMDR) (EM) Prior authorization required. Initial: 13 units per 90 days Concurrent: 13 units per 90 days Initial: Tx Plan and Service Order (valid for 1 year). Concurrent: Clinical information to address trauma symptoms; new Tx Plan/PCP annually. Family Therapy Codes: unmanaged outpatient visits per year. Visits can be individual/family or a combination of both. Authorization required once 26 unmanaged visits are exhausted. Concurrent: request cannot exceed 13 visits every 90 days. Crisis add-on codes are limited to 2 per year (no authorization required). LOCUS/CALOCUS: 1 ASAM: 1 Initial: Treatment (Tx) Plan /PCP and service order (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new TX Plan /PCP annually. Group Therapy Codes: 90849; unmanaged outpatient visits per year. Authorization is required once unmanaged visits are exhausted. LOCUS/CALOCUS: 1 ASAM: 1 Initial: Treatment (Tx) Plan /PCP and service order (valid for 1 year). Concurrent: group therapy requests (after the unmanaged visits) will be no more than 20 visits per 90 days. Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. 2

3 Outpatient Consultation Limit of 4 visits per year; does not count LOCUS/CALOCUS: 1 N/A Codes: against unmanaged visits. ASAM: Outpatient Individual Therapy: (GT); (SR); are add-on codes for an additional 30- minute crisis intervention 90833; and allow add-on codes when EM code occurs simultaneously. 26 unmanaged outpatient visits per year: Visits can be individual/family or a combination of both. Authorization required once 26 unmanaged visits are exhausted. Each 90-day request cannot exceed 13 visits. Crisis add-on codes are limited to 2 per year (no authorization required). LOCUS/CALOCUS: 1 ASAM: 1 Initial: Treatment (Tx) Plan /PCP and service order (valid for 1 year) Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. Developmental Testing: Ending 12/31/2018: Effective 1/1/19: 96110, 96112, episode of testing/year. 8 hours limit for all codes/year. Count as part of unmanaged visits/year. NA Psychological Testing Request serves as Service Order 3

4 Effective 1/1/19: , , 96130, , , Medicaid Child/Adolescent MH Services Benefit Plan Psychological Testing: 1 episode of testing/year. 8 hours limit for all codes/year. NA Psychological Testing Request serves as Service Order Ending 12/31/2018: Count as part of unmanaged visits/year. Neuropsychological Testing: Ending 12/31/2018: Effective 1/1/19: 96136, , 96138, , 96132, , 96116, , episode of testing/year. 8 hours limit for all codes/year. Count as part of unmanaged visits/year. NA Psychological Testing Request serves as Service Order 4

5 90837 (ZI) (ZI) (ZI) Medicaid Child/Adolescent MH Services Benefit Plan Trauma Focused-CBT: Prior authorization is required. * Initial: Treatment (Tx) Initial: 13 units per 90 days Plan/PCP and service order Concurrent: 13 units per 90 days (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. Trauma Intensive Comprehensive Clinical Assessment (TICCA): (TI) Prior authorization required. 1 hour= 1 unit. Up to 10 hours of assessment for a 3-month duration by Specialty Contract only. Does not count against unmanaged visits. * Clinical information to justify medical necessity. Up to 3 units may be approved if a TICCA Addendum is necessary. Therapeutic Injection: Up to 52 units per year. Does not require authorization. N/A Child/Adolescent Day Treatment: H2012 (HA) Initial: 60 days for maximum of 258 units. Concurrent: 60 days for maximum of 258 units. CALOCUS: 3-5 ASAM: A Initial: CCA, PCP, CCP, Service order; school documentation. Concurrent: Updated PCP and supporting documentation: progress notes, discharge planning. 5

6 Facility Based Crisis for Prior Authorization required. CALOCUS: 3-5 Children: ASAM: > 3.5 S9484 (HA) Initial/Concurrent: 24 units per day for up to 7 days. Annual limit 30 days from first day of admission. *Max of 30 calendar days within a consecutive 365-day period, unless EPSDT criteria is met. 8A-2 Initial: SAR submission within 72 hours of admission accompanied by treatment plan, psychiatric assessment, preadmission nursing screening, Comprehensive Clinical Assessment, PCP, Service Order, discharge plan. Family Centered Treatment (FCT): 6 months for 6 units CALOCUS: 3-5 ASAM: * Initial: CCA, PCP/CCP and service order on file. H2022 (HE) Intensive In-Home Services: Initial: 60 days for 36 units maximum. Concurrent: 60 days for 36 units maximum. CALOCUS: 3-5 ASAM: A Concurrent: Updated PCP Initial: CCA; PCP w/ccp and service order. H2022 Concurrent: Updated PCP with each request. 6

7 Multi-Systemic Therapy Initial: Pass through for 30 days/1unit CALOCUS: 3-5 8A (MST): ASAM: H2033 (M1)- Initial passthrough H2033 (M2) H2033 (M3) H2033 (M4) H2033 (M5) Concurrent: M2: 30 days for 1 unit M3: 30 days for 1 unit M4: 30 days for 1 unit M5: 30 days for 1 unit Initial: Notification SAR required; CCA, PCP, CCP and Service Order on file and submit w/second request. Concurrent: Updated PCP with each request. Psychiatric Residential Treatment Facility (PRTF): (AD): (DAP) Diversion and Assessment Program Initial: 30 days, 30 units. Concurrent: 30 days, 30 units. CALOCUS: 6 ASAM: D-1 Initial: CCA, CON, PCP, CCP, Service order. Concurrent: Updated PCP and Discharge Plan with each request. DAP referrals come through Care Coordination. Initial request does not require a CCA. Residential I & II: Level I, Family: H0046 Level II, Family-TFC: S5145 IAFT: S5145HA Level II, Program Type: H2020 Initial: 90 days Concurrent: 180 days CALOCUS: 3-5 ASAM: D-2 Initial: CCA, PCP and CCP, Service order. Concurrent: Updated PCP with each request. 7

8 Residential II: Trauma- Focused: Initial: 180 days CALOCUS: 3-5 ASAM: D-2 Initial: CCA, PCP and CCP, Service order S5145 (TF) TFC- Trauma Focused Cognitive Behavioral Therapy Concurrent: 180 days Service authorized per specialty contract Concurrent: Updated PCP with each request Residential: Rapid Response Bed TFC S5145 (US) Referral through Access required. Initial: pass-through 10 days. Concurrent: needs to be approved under EPSDT if over 21 days. N/A N/A Initial: UM creates SAR based on Access referral. Concurrent: Treatment (Tx) Plan/PCP in place and finding alternative placement. Residential Level III: H0019 (HQ): >4 beds H0019 (TJ): 5+ beds Initial: 60 days Concurrent: 60 days CALOCUS: 3.-5 ASAM: D-2 Initial: CCA, PCP and CCP, Service order. Concurrent: Updated PCP, Discharge Plan w/each request. Independent Psychiatric Evaluation at day

9 H0019 (HK): 4 beds or less H0019 (URL): 5 or more beds Medicaid Child/Adolescent MH Services Benefit Plan Residential Level IV: Initial: 60 days, 60 units CALOCUS: 4-5 8D-2 Initial: CCA, PCP and CCP, ASAM: Service order. Concurrent: 30 days, 30 units Concurrent: Updated PCP, Discharge Plan w/each request. Independent Psychiatric Evaluation at day 181. Task Treatment Alternative for Sexualized Kids: H2029 Initial: 13 units per 90 days. Concurrent: 13 units per 90 days. 1-year limit. Service authorized per Specialty Provider Contract. CALOCUS: 1-3 ASAM:.05-1 * Initial: Notification SAR Concurrent: Reports of number of sessions and type. Hours spent in skill development or case management activities. 9

10 Medicaid Child/Adolescent Substance Use (SU) Services Service Description Benefit Limit Level of Care Source Documentation ADATC-Ages (18-21): Acute 0128-Rehabilitation Initial: Up to 5 days Concurrent: Based on medical necessity; no more than 30 days total for both codes. CALOCUS: 5-6 ASAM: 3.7 Acute ASAM: 3.5 Non-acute 8A Requirements Initial: Prior Approval by Regional Referral Form, Live Review or Initial Inpatient Review Form. Concurrent: Inpatient Continuing Care Form. Substance Abuse Intensive Outpatient (SAIOP): H0015 (AD) Initial: Pass-through of 13 units for 30 days once per fiscal year. Concurrent: Up to 26 units for 60 days. An additional 2 weeks can be authorized if medically necessary. LOCUS: 3-5 ASAM: 2.1 8A Initial: PCP and CCP, Service order on file. Concurrent: First requestsubmit above with updated PCP w/each additional request. 10

11 NOTES * Indicates Partners In Lieu of Service Definition or Alternative Payment Agreement + Indicates an add-on code. Add-on codes cannot be billed separately and should be billed as an addition to a primary procedure code when applicable. Please consult the American Medical Association s CPT Code Book for complete details. Services requiring a PCP include the service order. A separate service order is indicated for those services for which a treatment plan and service order is required. Individual outpatient and family therapy services are not to exceed an average frequency of once weekly. Evaluation/Management services may be delivered by an MD, PA or NP. Evaluation/Management services for adult and children are not limited and do not require authorization. Interactive Complexity Code (90785) is used for individual psychophysiological therapy that incorporates biofeedback training by any modality that occurs face to face. Child and Adolescent Needs and Strengths (CANS) Comprehensive Assessment is required for services to children ages 0-5 years. The purpose is to facilitate linkage between the assessment process and individualized service plan. 11

12 MODIFIER INTERPRETATION AD Used to indicate that the service is for adolescent: Substance Abuse Intensive Outpatient: H0015AD Distinguishes Diversion & Assessment Program (DAP) PRTF, 911AD DJ Department of Justice for Transition to Community Living Program specific service codes EM Added to outpatient codes to designate Eye Movement Desensitization and Reprocessing (EMDR) services. EP Added to outpatient codes to designate smoking and tobacco use cessation GT Designates use of interaction telecommunication HE Designates use of Evidence Based Practice Family Centered Treatment H2022HE (Core Phase) versus (Engagement and Transition Phases) and Intensive In-Home Service H2022 HT Indicates Intensive Alternative Family Treatment (IAFT) Therapeutic Foster Care Code (S5145HT-TFC) M1-M5 Used with Multi-Systemic services to indicate the month of service H2033 (1-5) PB Added to Multi-Systemic Therapy (MST), H2033M to designate Problem Sexualized Behavior MST rate RR Indicates Rapid Response when attached to Therapeutic Foster Care code (S5145RR) SR Added to Outpatient Codes to designate In-Home Setting TF Added to Outpatient Codes and Residential Codes to indicate use of Trauma Focused Cognitive Behavioral Therapy delivered by a rostered provider who has a specialty contract with Partners. TI Designates the Trauma Intensive Comprehensive Clinical Assessment (TICCA) TI TK Attached to Alternative Codes to designate Transportation YA346TK; YA341TK.Attached to an Outpatient Code and refers to Treatment Alternative for Sexualized Kids (TASK) 90791TK. TL Therapeutic Leave U4 Designates B-3 services U5 In-Lieu of Service Definition ZI Added to Outpatient Codes to designate Trauma Focused Cognitive Behavioral Therapy 90837ZI; 90846ZI; 90847ZI Designates Family Centered Treatment (FCT) Engagement and Transition from Core Phases 12

13 Medicaid Benefit Plan Revision Information Date of Change Service and Section Revised Actual Change 7/7/2017 Ambulatory Detox Added a pass-through period 7/27/17 Non-Hospital Detox Added a pass-through period 8/1/17 Psychological Testing Replaced codes that were deleted from the grid in error 8/2/17 B3 Supported Employment (MH) Replaced pass-through that was deleted from the grid in error 8/14/17 B3 Supported Employment (MH) Extended authorization limit to 6 m 8/30/17 Ambulatory Detox Corrected pass-through information 9/6/17 B3 Individual Supports Clarified notification SAR requirement 11/13/17 TICCA Clarified hourly unit 2/2/18 Peer Support Clarified benefit limit 2/15/18 Residential Level III Shortened continued stay auth limit to 60 2/15/18 FCT Clarified option to group codes on one SAR 2/15/18 Facility Based Crisis for Children Added Service 3/23/18 Peer Support Removed notification SAR requirement 7/1/18 Update in Formatting Separated Benefit Plan by Age and/or Disability 11/1/18 EMDR; TICCA; ECT Added EMDR. Clarified units for TICCA. Clarified unmanaged units for ECT. 1/1/19 Developmental, Psychological, Neuropsychological Testing, FCT Updated Code changes 13