Behavioral Health Information Technology (BHIT) Program Billing Technical Specifications FINAL - V3.4 August 26 th, 2016 For Adult Behavioral Health (BH) Home and Community Based Services (HCBS)
Contents Purpose of the Document... 3 Description of elements contained in the document... 3 Business workflows... 3 Data flowcharts... 4 Spreadsheets of Template Forms and Fields... 4 Business Workflows... 6 Eligibility, Assessment and Authorization of Adult BH HCBS Services... 6 Data Workflows... 10 Data Capturing Diagram... 10 Data Flowchart... 12 Spreadsheets of Template Forms and Fields... 14 Demographics... 15 Case Documentation Staff Transportation Offsite Services... 17 Billing Specs... 19 Diagnostic Code for ALL HCBS Services... 20 Tiers and HCBS Thresholds... 22 Psychosocial Rehabilitation... 24 Habilitation... 33 Community Psychiatric Support and Treatment (CPST)... 36 Peer Supports (Empowerment Services)... 41 Family Support and Training... 44 Education Support Services... 48 Individualized Employment Support Services (IESS)... 51 Crisis Respite... 60 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 1
HCBS Staff Transportation when delivering offsite services... 66 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 2
Purpose of the Document This document summarizes the required technical specifications that need to be added into Electronic Behavioral Health Systems in order to meet the Case Documentation and Billing requirements for Adult Behavioral Health (includes mental health and substance use disorders) Home and Community Based Services (HCBS). The summary takes the following resources into consideration: New York State: Health and Recovery Plan (HARP) HCBS Provider Manual 9/18/2014 New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual - 9/1/2015 HCBS Services Overview- 10/22/2015 HARP HCBS Fee Schedule - 9/15/2015 HARP HCBS Rate Codes 1/8/2016 HCBS related webinars delivered by the Managed Care Technical Assistance Center (MCTAC) during 2015 and 2016 Description of elements contained in the document Business workflows In the following pages you will find two different business operation workflows: 1. Eligibility, Assessment and Authorization of Adult BH HCBS Services This work flow illustrates the major steps that had to take place at the Health Home Care Management Agency level in order to: o o o Determine eligibility to receive HCBS services for HARP enrolled members Conduct full assessment and develop a Plan of Care Obtain service authorization from Managed Care Organizations (MCOs) 2. Delivery of Adult BH HCBS services This workflow describes the different steps that HCBS network providers must complete: o o o o o o Complete an individual assessment for the specific HCBS service, develop an Individual Service Plan (including discharge plan) and obtain service authorization from member s MCO Deliver the authorized HCBS services while tracking approved frequency, duration and intensity of services Document each contact with a Case/Progress Note which includes required information Document extension and/or addition of services Conduct re-assessment or revise Individual Service Plan Create final discharge plan Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 3
Data flowcharts The document has incorporated two diagrams to model how data flows within the EHR software used by HCBS providers. 1. Data Capturing Diagram This diagram illustrates the major steps that each HCBS provider must complete including required data and information to be electronically input into the EHR system. This diagram assumes that the HCBS provider already has an EHR that has been configured and is currently being used (live). The diagram shows the: o o o Intake of the HCBS member and creation of the electronic chart Use of different forms as required to perform the different steps defined in the "Delivery of Adult BH HCBS Services" workflow Identify which steps are billable 2. Data Flowchart This diagram describes how values existing in different modules of the EHR software are being "pulled" into different forms during the delivery of the services in order to minimize multiple inputs of repeated data. o o The diagram models how data interacts within the EHR system The diagram only includes sample fields for illustration purposes Spreadsheets of Template Forms and Fields Different spreadsheets were created in order to detail minimum required fields by template form. To facilitate the navigation of the spreadsheets, we have divided the information into two major types: 1. Demographics HCBS Identifier Care Manager Information 2. Billing Specs per Service a. Psychosocial Rehabilitation Use Case 1: Psychosocial Rehab - Individual Onsite Use Case 2: Psychosocial Rehab - Individual Offsite Use Case 3: Psychosocial Rehab - Individual Per Diem - Onsite or Offsite Use Case 4: Psychosocial Rehab - Group 2-3 Use Case 5: Psychosocial Rehab - Group 4-5 Use Case 6: Psychosocial Rehab - Group 6-10 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 4
b. Habilitation c. Community Psychiatric Support and Treatment (CPST) Use case 1: If practitioner is a Physician Use case 2: If practitioner is a NP or Psychologist Use case 3: If practitioner is a RN, LMHC, LMFT, LCSW, or LMSW Use case 4: If practitioner is ALL OTHER allowable professions (OMH-Certified Peer, OASAS-Certified Peer, CASAC, CASAC-T) d. Peer Support e. Family Support and Training Use Case 1: If the service is delivered to an INDIVIDUAL Use Case 2: If the service is delivered to a GROUP of 2 or 3 f. Education Support Services g. Employment Use Case 1: If the service is PRE-VOCATIONAL Use Case 2: If the service is TRANSITIONAL Employment Use Case 2: If the service is HCBS INTENSIVE Supported Employment Use Case 4: If the service is HCBS ON-GOING Supported Employment h. Crisis Respite Use Case 1: If the service is HCBS Short-term Crisis Respite (dedicated facility) Use Case 2: If the service is HCBS Intensive Crisis Respite Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 5
Business Workflows Eligibility, Assessment and Authorization of Adult BH HCBS Services This work flow illustrates the major steps that had to take place at the Health Home Care Management Agency level in order to: o Determine eligibility to receive HCBS services for HARP enrolled members o Conduct full assessment and develop a Plan of Care o Obtain service authorization from Managed Care Organizations (MCOs) Please Note: The Eligibility, Assessment and Authorization of Adult BH HCBS Services Workflow is for informational purposes only. These steps happen prior to the involvement of the HCBS provider. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 6
Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 7
Delivery of Adult BH HCBS Services This workflow describes the different steps that HCBS network providers must complete: o Complete an individual assessment for the specific HCBS service, develop an Individual Service Plan (including discharge plan) and obtain service authorization from member s MCO o o o o o Deliver the authorized HCBS services while tracking approved frequency, duration and intensity of services Document each contact with a Case/Progress Note which includes required information Document extension and/or addition of services Conduct re-assessment or revise Individual Service Plan Create final discharge plan Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 8
Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 9
Data Workflows Data Capturing Diagram This diagram illustrates the major steps that each HCBS provider must complete including required data and information to be electronically input into the EHR system. This diagram assumes that the HCBS provider already has an EHR that has been configured and is currently being used (live). The diagram shows the: o Intake of the HCBS member and creation of the electronic chart o o Use of different forms as required to perform the different steps defined in the "Delivery of Adult BH HCBS Services" workflow Identify which steps are billable Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 10
Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 11
Data Flowchart This diagram describes how values existing in different modules of the EHR software are being "pulled" into different forms during the delivery of the services in order to minimize multiple inputs of repeated data. o o The diagram models how data interacts within the EHR system The diagram only includes sample fields for illustration purposes Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 12
E.H.R. modules Company Configuration Direct Service Staff HCBS Recipient Profile Billing Configuration ADULT BH HCBS Services FORMS Fields HCBS Provider Assessment Individual Service Plan Authorization Request Progress/Visit Notes Discharge Claims HCBS Provider organization Medicaid NPI Service Location Name Service Location Address Phone Number Tax ID/TIN First Name Last Name Title NPI # or Credential # Non-Licensed Certification First Name Last Name Street Address City State Zip Code Medicaid # Plan Memebr ID Type of HCBS Service Procedure Code/Description Modifier Rate Code Specialty Code Unit Measure Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 13
Spreadsheets of Template Forms and Fields Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 14
Demographics Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 15
Demographics Required HCBS identifier It is required to add an identifier to the electronic chart indicating that the person is a HCBS recipient. Depending of the architecture of each solution this value could be added, for example, as part of a service program or in the demographic module. Case Manager It is required to add the Case Manager's information to the electronic chart. The Case Manager takes the place of the Referring Provider for HCBS members. Depending of the architecture of each solution these fields may exist. If not, the following values should be added: Care Manager First Name Care Manager Last Name Care Manager Agency/Health Home Name Care Manager Agency/Health Home Address Care Manager Phone Care Manager Email Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 16
Case Documentation Staff Transportation Offsite Services Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 17
CASE DOCUMENTATION Specs Adult BH HCBS Assessment Template Form Progress Note Final Visit Template Form HCBS Staff Transportation costs when delivering offsite services Value of Location Type = Offsite Label of Field Field Type Editable, calculated or auto-populated? Comments Use Case 1: HCBS Staff uses public transportation Cost of Subway (roundtrip NYC) Number Fixed amount: $5.50 Use Case 2: HCBS Staff uses mileage Starting mileage Number Editable 58 cents per mile, up to 60 Ending mileage Number Editable miles per round trip Total mileage Number Calculated Cost Number Calculated (Total mileage *.58) Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 18
Billing Specs Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 19
Diagnostic Code for ALL HCBS Services Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 20
Diagnostic code for all HCBS Services HCBS services do not require diagnosis since these are rehabilitation services. However, for claims processing, MCOs do require a diagnostic code. ALL HCBS Services should use the R69 code to complete that field. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 21
Tiers and HCBS Thresholds Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 22
Tiers and HCBS Utilization Thresholds BILLING Specs Types of Tiers that apply to HCBS Services Tier I services include Individualized Employment Support Services (IESS), Education and Peer Supports services. Please note that Individualized Employment Support Services (IESS) includes 4 separate and distinct levels of service: Pre-vocational Transitional Intensive employment support Ongoing employment support Tier 2 includes the full array of HCBS HCBS Utilization Thresholds HCBS services will be subject to utilization caps at the recipient level that apply on a rolling basis (any 12 month period). These limits will fall into three categories: 1. Tier 1 HCBS services will be limited to $8,000 as a group. There will also be a 25% corridor on this threshold that will allow plans to go up to $10,000 without a disallowance. 2. There will also be an overall cap of $16,000 on HCBS services (Tier 1 and Tier 2 combined). There will also be a 25% corridor on this threshold that will allow plans to go up to $20,000 without a disallowance. 3. Both cap 1 and cap 2 are exclusive of crisis respite. The two crisis respite services are limited within their own individual caps (7 days per episode, 21 days per year). If a Plan anticipates they will exceed any limit for clinical reasons they should contact the HARP medical director from either OMH or OASAS and get approval for a specific dollar increase above the $10,000 effective limit. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 23
Psychosocial Rehabilitation Use Case 1: Psychosocial Rehab - Individual Onsite Use Case 2: Psychosocial Rehab - Individual Offsite Use Case 3: Psychosocial Rehab - Individual Per Diem - Onsite or Offsite Use Case 4: Psychosocial Rehab - Group 2-3 Use Case 5: Psychosocial Rehab - Group 4-5 Use Case 6: Psychosocial Rehab - Group 6-10 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 24
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs The following values apply to all Use Cases/Scenarios Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H2017 psychosocial rehabilitation; per 15 minutes Specialty code Picklist Auto-populate from Billing Configuration 836 epaces code Picklist Editable H3 H6 Site name Picklist Editable Multiple options are Read from table of possible locations of provider Service limits Number Editable NA Do not bill transportation supplement Rules for All Psychosocial Rehabilitation Services (PSR): HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Services must be offered in the setting best suited for desired outcomes, including home, or other community-based setting in compliance with Medicaid regulations. The setting may include programs that are peer driven/operated or peer informed and that provide opportunities for drop-in. Services may be provided individually or in a group setting and should utilize (with documentation) evidence-based rehabilitation and recovery. The program should utilize all goal-directed individual and group task to meet the goals identified above. On or off site These services may complement, not duplicate, services aimed at supporting an individual to achieve an employment-related goal in their plan of care. The total combined hours for Psychosocial Rehabilitation and Community Psychiatric Support and Treatment are limited to no more than a total of 500 hours in a calendar year. Providers of service may include unlicensed behavioral health staff (see appendix). Workers who provide PSR services should periodically report to a supervising licensed practitioner on participants progress toward the recovery and re-acquisition of skills Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 25
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs The following values apply to distinct Use Cases/Scenarios Use Case 1: Psychosocial Rehab - Individual Onsite Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable U1 Level 1 (state defined) Do not bill transportation supplement. Rate Code Picklist Auto-populate from Billing Configuration 7784 Adult BH HCBS Psychosocial Rehab - Individual onsite Place of service (CMS) Picklist Editable Multiple options are Read from Table of predefined Office possible sites from CMS Individual or Group List Editable Individual 7784, 7785 and 7789 rate codes are prohibited on the same day Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 8 units (2 hours) NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $14.25 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 26
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs Use Case 2: Psychosocial Rehab - Individual Offsite Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable U2 Level 2 (State defined) Bill transportation supplement as appropriate. Rate Code Auto-populate from Billing Configuration 7785 Adult BH HCBS Psychosocial Rehab - Individual offsite 7784, 7785 and 7789 rate codes are prohibited on the same day Place of service (CMS) Picklist Editable Multiple options are possible Read from Table of predefined sites from CMS Individual or Group List Editable Individual Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 8 units (2 hours) NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $16.60 Rules for Psychosocial Rehabilitation (PSR): Individual, per 15 minutes Onsite and Offsite Billed daily in 15 minute units with a limit of 8 units per day. Individual service may be billed the same day as a PSR group session. Individual service (15 minute unit billing) cannot be billed on the same day as a PSR Individual per diem. May be provided on or offsite (two separate rates apply). Transportation is billed separately as appropriate. Maximum of 8 units (2 hours) per day. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 27
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs Use Case 3: Psychosocial Rehab - Individual Per Diem - Onsite or Offsite Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable NA Rate Code Number Auto-populate from Billing Configuration 7789 HCBS Psychosocial Rehab - per diem. Individual onsite or offsite Place of service (CMS) Picklist Editable Multiple options are Read from Table of predefined possible sites from CMS Individual or Group List Editable Individual Unit measure Number Editable Per diem Unit Limits (Claim line level) Number Editable 1 unit NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $180.00 Rules for Psychosocial Rehabilitation (PSR): Individual, per diem Billed daily with a max of 1 unit. Due to the long duration of these sessions, the PSR Individual per diem service may not be billed the same day as a PSR group session Individual per diem service cannot be billed the same day as PSR Individual per 15 minutes. May be provided on or offsite - under a single rate code and payment amount. 7784, 7785,7786, 7787, 7788 and 7789 rate codes are prohibited on the same day Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Minimum of 3 hours. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 28
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs Use Case 4: Psychosocial Rehab - Group 2-3 Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable UN or UP UN-Level 2 (State defined), UP- Three patients served Rate Code Number Auto-populate from Billing Configuration 7786 Adult BH HCBS Psychosocial Rehab - Individual onsite or offsite 7786, 7787, 7788 and 7789 rate codes are prohibited on the same day Place of service (CMS) Picklist Editable Multiple options are possible Individual or Group List Editable Group Unit measure Number Editable Per 15 minutes Read from Table of predefined sites from CMS Unit Limits (Claim line level) Number Editable 4 units (1 hours) NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $7.85 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 29
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs Use Case 5: Psychosocial Rehab - Group 4-5 Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable UQ or UR UQ- Four patients served, UR- Five patients served Rate Code Number Auto-populate from Billing Configuration 7787 Adult BH HCBS Psychosocial Rehab - Individual onsite or offsite 7786, 7787, 7788 and 7789 rate codes are prohibited on the same day Place of service (CMS) Picklist Editable Multiple options are possible Individual or Group List Editable Group Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 4 units (1 hours) NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $3.95 Read from Table of predefined sites from CMS Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 30
Adult BH HCBS service Psychosocial Rehabilitation BILLING Specs Use Case 6: Psychosocial Rehab - Group 6-10 Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable US US- Six or more patients served Rate Code Number Auto-populate from Billing Configuration 7788 HCBS Psychosocial Rehab - Individual onsite or offsite Place of service (CMS) Picklist Editable Multiple options are possible Individual or Group List Editable Group Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 4 units (1 hours) NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $2.65 Read from Table of predefined sites from CMS Rules for Psychosocial Rehabilitation (PSR): Group Billed daily in 15 minute units with a limit of 4 units per day. Group sessions may be billed on the same day as a PSR individual per 15 minutes. Group sessions may not be billed on the same day as a PSR Individual per diem session. Service must be offered in the setting best suited for desired outcomes. Maximum 4 units (1 hour) per day. Payment for group sessions is broken into various levels through the use of Px modifier codes to distinguish the number of individuals present in the session (i.e., 2-3, 4-5, 6+). Bill staff transportation supplement as appropriate (but only for a single recipient). 7786, 7787, 7788 and 7789 rate codes are prohibited on the same day Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 31
Psychosocial Rehabilitation (PSR) Limitations/Exclusions These services may complement, not duplicate, services aimed at supporting an individual to achieve an employment-related goal in their plan of care. The total combined hours for Psychosocial Rehabilitation and Community Psychiatric Support and Treatment are limited to no more than a total of 500 hours in a calendar year. Certification/Provider Qualifications Providers of service may include unlicensed behavioral health staff (see appendix). Workers who provide PSR services should periodically report to a supervising licensed practitioner on participants progress toward the recovery and re-acquisition of skills. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 32
Habilitation Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 33
Adult BH HCBS service Habilitation BILLING Specs Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable T2017 Habilitation, residentialwaiver, 15 min Modifier List Editable N/A Specialty code Picklist Auto-populate from Billing Configuration 854 Rate Code Auto-populate from Billing Configuration 7795 epaces code Picklist Editable H3, H6 Place of service (CMS) Picklist Editable Multiple options are possible Site name Picklist Editable Multiple options are possible Individual or Group List Editable Multiple options are possible Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 12 units Service limits Number Editable N/A NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $17.25 Rules for Habilitation: HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Read from Table of pre-defined sites from CMS Read from table of locations of provider Individual or Group Bill Staff Transportation supplement as appropriate. If billed with PSR, both services must be provided by the same provider. Billed daily in 15 minute increments with a limit of 12 units (3 hours) per day. There are no group sessions for this service. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 34
Habilitation Limitations/Exclusions Habilitation services are limited to no more than a total of 250 hours in a calendar year. Time limited exceptions to this limit for individuals transitioning from institutions are permitted if prior authorized and found to be part of the cost-effective package of services provided to the individual compared to institutional care. Certification/Provider Qualifications Unlicensed Staff (see appendix) may provide this service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 35
Community Psychiatric Support and Treatment (CPST) Use case 1: If practitioner is a Physician Use case 2: If practitioner is a NP or Psychologist Use case 3: If practitioner is a RN, LMHC, LMFT, LCSW, or LMSW Use case 4: If practitioner is ALL OTHER allowable professions (OMH-Certified Peer, OASAS-Certified Peer, CASAC, CASAC-T) Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 36
Adult BH HCBS service Community Psychiatric Support and Treatment (CPST) BILLING Specs The following values apply to all Use Cases/Scenarios Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H0036 Community Psychiatric Supportive Treatment, face-to-face; per 15 min Specialty code Picklist Editable 839 epaces code Picklist Editable H3 H6 Place of service (CMS) Picklist Editable Multiple options are possible Read from Table of pre-defined sites from CMS Bill Staff Transportation separately Offsite only Site name Picklist Editable Multiple options are possible Read from table of locations of provider Individual or Group List Editable Individual Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 6 units Service limits Number Editable NA Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 37
Adult BH HCBS service Community Psychiatric Support and Treatment (CPST) BILLING Specs The following values apply to distinct Use Cases/Scenarios Use case 1: If practitioner is a Physician Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable AF Specialty Physician Rate Code Number Auto-populate from Billing Configuration 7790 HCBS Community Psychiatric Supportive Treatment - Individual offsite only NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $83.85 Use case 2: If practitioner is a NP or Psychologist Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable SA or AH SA-Nurse Practitioner, AH- Clinical psychologist Rate Code Number Auto-populate from Billing Configuration 7791 NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $43.60 Use case 3: If practitioner is a RN, LMHC, LMFT, LCSW, or LMSW Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable TD or AJ TD- Registered nurse, AJ- Clinical Social Worker (also allowing LMSW) Rate Code Number Auto-populate from Billing Configuration 7792 NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $34.90 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 38
Adult BH HCBS service Community Psychiatric Support and Treatment (CPST) BILLING Specs Use case 4: If practitioner is a ALL OTHER allowable professions Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Modifier List Editable N/A Rate Code Number Auto-populate from Billing Configuration 7793 NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $18.10 Rules for Community Psychiatric Support and Treatment (CPST): HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Billed daily in 15 minute increments with a limit of 6 units (1½ hours) per day. Payment for CPST services is broken into various levels through the use of Px modifier codes that indicate the type of staff providing the service (i.e., physician, psychologist, NP, RN, all other professions). There are no group sessions for this service. May only be provided offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 39
Community Psychiatric Support and Treatment (CPST) Limitations/Exclusions Community treatment for eligible individuals can continue as long as needed, within the limits, based on the individual s needs. The intent of this service is to eventually transfer the care to a place based clinical setting. The total combined hours for CPST and Psychosocial Rehabilitation (PSR) and are limited to no more than a total of 500 hours in a calendar year. Certification/Provider Qualifications Agencies who have experience providing similar services should already have a license to provide treatment services (i.e., Clinics, PROS, Intensive Psychiatric Rehabilitation Treatment (IPRT), Partial Hospitalization, Comprehensive Psychiatric Emergency Programs (CPEP), or currently utilize an evidence based or best practice offsite treatment model using licensed professionals. Licensed staff (see appendix) must provide this service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 40
Peer Supports (Empowerment Services) Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 41
Adult BH HCBS service Peer Supports (Empowerment Services) - by credentialed staff BILLING Specs Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H0038 Self Help/Peer Service, pet 15 min Modifier List Editable HE or HF HE- Mental health program, HF-Substance abuse program Specialty code Picklist Auto-populate from Billing Configuration 837 Rate Code Auto-populate from Billing Configuration 7794 epaces code Picklist Editable H2,H3, H5,H6 Place of service (CMS) Picklist Editable Multiple options are possible Read from Table of predefined sites from CMS Site name Picklist Editable Multiple options are possible Read from table of locations of provider Individual or Group List Editable Multiple options are possible Individual or Group Unit measure Number Editable Per 15 minutes Unit Limits (Claim line level) Number Editable 16 units Service limits Number Editable NA NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $14.50 Rules for Peer Supports: HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Bill Staff Transportation supplement as appropriate Use HE modifier for an "OMH service" or the HF modifier for an "OASAS service". Billed daily in 15 minute units with a limit of 16 units (4 hours) per day. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 42
Peer Supports (Empowerment Services) Limitations/Exclusions Peer support services are limited to no more than a total of 500 hours in a calendar year. Individuals receiving SUD outpatient treatment may not receive Peer Supports, if they are receiving an OASAS state plan peer service. Note: peer services while an individual is incarcerated or institutionalized are not Medicaid reimbursable. Time spent on the phone with individuals is not Medicaid reimbursable. The cost of admission to an event (i.e., sports event or concert) is not Medicaid reimbursable. Advocacy for community improvement (not specific to the Medicaid eligible individual) is not Medicaid reimbursable. Certification/Provider Qualifications Peer support providers must have a certification as of the following: O MH established Certified Peer Specialist OASAS Certified Peer Advocate Certified Peer Specialists are appropriately supervised treatment team members who will play an integral role in care planning including the Wellness Recovery Action Plan (WRAP), treatment planning and the development of psychiatric advance directives (PAD). Training for Peer Specialists will be provided/contracted by OMH and OASAS and will focus on the principles and concepts of recovery, coping skills, and advocacy, the unique competencies needed to assist another individual based on the shared personal experience paradigm. Supervision of peer support must be provided by a licensed behavioral health practitioner. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 43
Family Support and Training Use Case 1: If the service is delivered to an INDIVIDUAL Use Case 2: If the service is delivered to a GROUP of 2 or 3 Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 44
Adult BH HCBS service Family Support/Training BILLING Specs The following values apply to all Use Cases/Scenarios Field Name (label) Field type Field Function Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H2014 Skills training and development; per 15 min Specialty code Picklist Auto-populate from Billing Configuration 855 epaces code Picklist Editable H3, H6 Place of service (CMS) Picklist Editable Multiple options are possible Read from Table of pre-defined sites from CMS Bill Staff Transportation supplement as appropriate Site name Picklist Editable Multiple options are possible Read from table of locations of provider Unit measure Number Editable Per 15 min Unit Limits (Claim line level) Number Editable 1 unit Service limits Number Editable 12 units Rules for Family Support and Training (FST) HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 45
Adult BH HCBS service Family Support/Training BILLING Specs The following values apply to distinct Use Cases/Scenarios Use Case 1: If the service is delivered to an INDIVIDUAL Field Name (label) Field type Field Function Allowed ONLY Possible values Description Comments/Observations Modifier List Editable HR or HS HR-family with client present, HS-family Use modifiers without client present Rate Code Auto-populate from Billing Configuration 7799 7799 and 7800 rate codes are prohibited on the same day Individual or Group List Editable Individual NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $16.60 Rules for Family Support and Training (FST): FST session provided to one family Billed daily in 15 minute increments with a limit of 12 units per day. FST is detailed by using modifiers that indicate whether the service was provided to the family with the recipient present or to the family without the recipient present. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Use Case 2: If the service is delivered to a GROUP of 2 or 3 Field Name (label) Field type Field Function Allowed ONLY Possible values Description Comments/Observations Modifier List Editable HR or HS, HN HR-family with client present, HS-family Use modifiers or UP without client present; HN- integrated mental health/substance abuse program, UP-three patients served Rate Code Auto-populate from Billing Configuration 7800 7799 and 7800 rate codes are prohibited on the same day Individual or Group List Editable Group NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $9.15 Rules for Family Support and Training (FST): Group FST (consists of 2-3 families) Billed daily in 15 minute increments with a limit of 6 units (1.5 hours) per day. Group sessions may be billed on the same day as an FST one family session. May be provided on or offsite. Payment for FST group sessions is differentiated through the use of Px modifier codes to distinguish the number of families present in the session (i.e., 2 or 3). Billing is at the recipient (family level (e.g., if the group consists of the families of three recipients and, for purposes of this example, eight people are in the group, there would be only three claims submitted). Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 46
Family Support and Training Limitations/Exclusions The total combined hours for Family Support and Training are limited to no more than a total of 40 hours in a calendar year. Certification/Provider Qualifications Unlicensed staff (see appendix) may provide this service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 47
Education Support Services Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 48
Adult BH HCBS service Education Support Services BILLING Specs Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable T2013 Habilitation educational, waiver Modifier List Editable N/A Specialty code Picklist Auto-populate from Billing Configuration 862 Rate Code Auto-populate from Billing Configuration 7805 epaces code Picklist Editable H2,H3, H5,H6 Place of service (CMS) Picklist Editable Multiple options are possible Site name Picklist Editable Multiple options are possible Individual or Group List Editable Individual Unit measure Number Editable Per hour Read from Table of pre-defined sites from CMS Read from table of locations of provider Bill Staff Transportation supplement as appropriate Unit Limits (Claim line level) Number Editable 2 units Must comply with VP/IDEA restrictions Service limits Number Editable N/A NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $74.80 Rules for Education Support Services: HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Billed daily in 1 hour units with a max units of 2 (2 hours). May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 49
Education Support Services Limitations/Exclusions The hours for supported education are limited to no more than a total of 250 hours per year. Documentation is maintained in the file of each individual receiving this service that the service is not otherwise available under section 110 of the Rehabilitation Act of 1973 or the IDEA. Can only access this service if other appropriate state plan services are not available or appropriate. Certification/Provider Qualifications Education Specialists should possess a BA, and two years of experience supporting individuals in pursuing education goals. A supervisor may be unlicensed (see appendix) and requires a minimum of a BA (preferably a Masters in Rehabilitation or a relevant field), a minimum of three years of relevant work experience preferably as an education specialist. All staff should have minimum of two years working in the behavioral health. Staff should have knowledge in the following areas: disability accommodations and assistive technology, financial aid, student loan default, SUD recovery resources on campus, etc. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 50
Individualized Employment Support Services (IESS) Use Case 1: If the service is PRE-VOCATIONAL Use Case 2: If the service is TRANSITIONAL Employment Use Case 2: If the service is HCBS INTENSIVE Supported Employment Use Case 4: If the service is HCBS ON-GOING Supported Employment Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 51
Adult BH HCBS service Pre-vocational and Employment BILLING Specs The following values apply to all Use Cases/Scenarios Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations epaces code Picklist Editable H2,H3, H5,H6 Place of service (CMS) Picklist Editable Multiple options are possible Site name Picklist Editable Multiple options are possible Individual or Group List Editable Individual Unit measure Number Editable Per hour Read from Table of pre-defined sites from CMS Read from table of locations of provider Unit Limits (Claim line level) Number Editable 2 unit Must comply with VP/IDEA restrictions Service limits Number Editable N/A Rules for All Employment Services: HCBS Provider Assessment, ISP and Authorization must be completed in 3 visit within 14 days Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 52
Adult BH HCBS service Pre-vocational and Employment BILLING Specs The following values apply to distinct Use Cases/Scenarios Use Case 1: If the service is PRE-VOCATIONAL Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable T2015 Habilitation prevocational, waiver; per hour Modifier List Editable N/A Specialty code Picklist Auto-populate from Billing Configuration 858 Bill Staff Transportation supplement as appropriate Rate Code Auto-populate from Billing Configuration 7801 7801, 7802,7803,7804 rate codes are prohibited on the same day NYC Fee (paid to provider) Number Auto-populate from Billing Configuration $74.80 Rules for Employment Services: Pre-Vocational Services Billed daily in 1 hour units with a limit of 2 units (2 hours) per day. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 53
Adult BH HCBS service Pre-vocational and Employment BILLING Specs Use Case 2: If the service is TRANSITIONAL Employment Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable T2019 Habilitation, supported employment, waiver; per 15 min Modifier List Editable N/A Specialty code Picklist Auto-populate from System 859 Bill Staff Transportation supplement as appropriate Rate Code Auto-populate from System 7802 7801, 7802, 7803,7804 rate codes are prohibited on the same day NYC Fee (paid to provider) Number Auto-populate from System $18.70 Rules for Employment Services: Transitional Employment Billed daily in 15 minute units with a limit of 12 units (3 hours) per day. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 54
Adult BH HCBS service Pre-vocational and Employment BILLING Specs Use Case 3: If the service is HCBS INTENSIVE Supported Employment Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H2023 Supported Employment Bill Staff Transportation supplement as appropriate Modifier List Editable TG Complex Level of Care Specialty code Picklist Auto-populate from System 860 Rate Code Auto-populate from System 7803 7801,7802, 7803, 7804 rate codes are prohibited on the same day NYC Fee (paid to provider) Number Auto-populate from System $18.70 Rules for Employment Services: Intensive Supported Employment (ISE) Billed daily in 15 minute units with a limit of 12 units (3 hours) per day. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Modifier is used to indicate Complex Level of Care. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 55
Adult BH HCBS service Pre-vocational and Employment BILLING Specs Use Case 4: If the service is HCBS ON-GOING Supported Employment Label of Field Field Type Editable, calculated or auto-populated? Allowed ONLY Possible values Description Comments/Observations Code(s) of service Picklist Editable H2025 On-going support to maintain employment, per 15 min Modifier List Editable N/A Specialty code Picklist Auto-populate from System 861 Bill Staff Transportation supplement as appropriate Rate Code Auto-populate from System 7804 7801,7802,7803, 7804 rate codes are prohibited on the same day NYC Fee (paid to provider) Number Auto-populate from System $18.70 Rules for Employment Services: ON-GOING Supported Employment (ISE) Billed daily in 15 minute units with a limit of 12 units (3 hours) per day. May be provided on or offsite. Staff transportation is billed separately as appropriate. Transportation claiming is done at the recipient level and then is only for a single staff member, regardless of the number of persons involved in providing the service. Billing technical specifications for Adult Behavioral Health Home and Community Based Services (HCBS) Version 3.4 Page 56