OPTUM MEDICARE COVERAGE SUMMARY: HEALTH AND BEHAVIOR ASSESSMENT AND INTERVENTION MEDICARE COVERAGE SUMMARY: HEALTH AND BEHAVIOR ASSESSMENT AND INTERVENTION Guideline Number: Effective Date: June, 2017 INTRODUCTION Medicare Cverage Summaries synpsize guidance prvided in CMS Natinal Cverage Determinatins (NCDs) and Lcal Cverage Determinatins (LCDs), and are used t make medical necessity determinatins fr Medicare behaviral health benefits managed by Optum and U.S. Behaviral Health Plan, Califrnia (ding business as OptumHealth Behaviral Slutins f Califrnia ( Optum-CA )). In the event that CMS des nt prvide a NCD r a LCD fr a particular State, jurisdictin, cnditin r service, Optum s Level f Care Guidelines shuld be used fr medical necessity decisins alng with the member s benefit plan. Befre using this guideline, please check the member s specific benefit plan requirements and any federal r state mandates, if applicable. HEALTH AND BEHAVIOR ASSESSMENT AND INTERVENTION The fllwing describes Medicare cvered Health and Behavir (H&B) assessment and interventin accrding t existing Lcal Cverage Determinatins (LCDs). Health & Behavir (H&B) assessment and interventin prcedures are used t identify and address psychlgical, behaviral, emtinal, cgnitive, and scial factrs imprtant t the preventin, treatment, r management f physical health prblems. The fcus is nt n mental health, but n the bipsychscial factrs imprtant t physical health prblems and treatments (CMS Lcal Cverage Determinatin, 2017). Health and Behavir Interventin prcedures are used t mdify the psychlgical, behaviral, emtinal, cgnitive and scial factrs identified as imprtant t r directly affecting the patient s physilgical functining, disease status, health, and well-being. The fcus f the interventin is t imprve the patient s health and wellbeing utilizing cgnitive, behaviral, scial, and/r psychphysilgical prcedures designed t amelirate specific disease-related prblems (CMS Lcal Cverage Determinatin, 2017). Apprpriate use f H&B services includes the fllwing (CMS Lcal Cverage Determinatin, 2017): A medical diagnsis is required as the primary diagnsis and the member des nt meet criteria fr a psychiatric diagnsis. All H&B services must be perfrmed by a Clinical Psychlgist. Page 1 f 6
APPLICABLE STATES A physician may nt use an H&B assessment and interventin prcedure cde. Prviders delivering H&B assessment and interventin prcedures must d s within the scpe f their prfessinal training and licensure. The initial and reassessment is limited t a 1 hur visit r 4 15-minute services, and the interventin is limited t a maximum f 30 minutes per day. Health and Behavir Assessment & Interventin cverage is nly applicable if delivered in the fllwing States/jurisdictins at the time this guideline was written (CMS LCD, 2017). If services are nt delivered in ne f the fllwing states, please apply the Optum Level f Care Guidelines: Benefits Flrida Puert Ric Virgin Islands Benefits include the fllwing services: Diagnstic evaluatin and assessment Treatment planning Referral services Medicatin management Psychtherapy Crisis interventin+ Behaviral Health care services r supplies are prvided when needed t prevent, diagnse, r treat an illness, injury, cnditin, disease, r its symptms and that meet accepted standards f medicine (Medicare.gv, Glssary, 2017). Limitatins and Exclusins The requested service r prcedure fr the treatment f a mental health cnditin must be reviewed against the language in the enrllee's Evidence f Cverage/Summary f Benefits. When the requested service r prcedure is limited r excluded frm the enrllee s EOC, r is therwise defined differently, it is the terms f the enrllee s EOC/SB that prevails. Additinal Infrmatin The lack f a specific exclusin fr cverage fr a service des nt imply that the service is cvered. N payment can be made fr certain items and services, when the fllwing cnditins exist (CMS Benefit Plicy Manual, Chapter 16, Sectin 10, 20 & 110, Nvember, 2014): Nt reasnable and necessary: Items and services which are nt reasnable and necessary fr the diagnsis r treatment f illness r injury r t imprve functining are nt cvered. Custdial care: Persnal care that des nt require the cntinuing attentin f trained medical r paramedical persnnel. In determining whether a persn is receiving custdial care, the intermediary r carrier cnsiders the level f care and medical supervisin required and furnished. It des nt base the decisin n diagnsis, type f cnditin, degree f functinal limitatin, r rehabilitatin ptential. Excluded Investigatinal Devices r Prcedures: These items and prcedures include any prcedure, study, test, drug, equipment r facility still underging study and which is generally nt accepted as standard therapy in the medical cmmunity where alternative therapy exists. are nt cnsidered reasnable and necessary t (CMS LCD, 2017): Update r educate the family abut the patient s cnditin Educate nn-immediate family members, nn-primary care-givers, nn-guardians, the nn-health care prxy, and ther members f the treatment team, e.g., health aides, nurses, physical r ccupatinal therapists, hme health aides, persnal care attendants and c-wrkers abut the patient s care plan. Page 2 f 6
Treatment-planning with staff Mediate between family members r prvide family psychtherapy Educate diabetic patients and diabetic patients family members Deliver Medical Nutritin Therapy Maintain the patient s r family s existing health and verall well-being Prvisin f supprt services, nt requiring the skills f a Clinical Psychlgist (CP). Prvide persnal, scial, recreatinal, and general supprt services. These services may be valuable adjuncts t care; hwever, they are nt psychlgical interventins. Examples f services that are nt cnsidered H&B prcedures (CMS LCD, 2017): Stress management fr supprt staff Replacement fr expected nursing hme staff functins Recreatinal services, including dance, play, r art Music appreciatin and relaxatin Craft skill training Cking classes Cmfrt care services Individual scial activities Teaching scial interactin skills Scializatin in a grup setting Retraining cgnitin due t dementia General cnversatin Services directed tward making a mre dynamic persnality Cnsciusness raising Vcatinal r religius advice General educatinal activities Tbacc withdrawal supprt Caffeine withdrawal supprt Visits fr lneliness relief Sensry stimulatin Games, including bing games Prjects, including shpping utings, even when used t reduce a dysphric state Teaching grming skills Grming services Mnitring activities f daily living Teaching the patient simple self-care Teaching the patient t fllw simple directives Wheeling the patient arund the facility Orienting the patient t name, date, and place Exercise prgrams, even when designed t reduce a dysphric state Memry enhancement training Weight lss management Page 3 f 6
Case management services including but nt limited t planning activities f daily living, arranging care r excursins, r reslving insurance prblems Activities principally fr diversin Planning fr milieu mdificatins Cntributins t patient care plans Maintenance f behaviral lgs H&B Interventin Service Criteria H&B Initial Assessment (CPT Cde 96150), Reassessment (96151), and Interventin services (CPT Cdes 96152-96154) are cnsidered reasnable and necessary when the fllwing criteria are met: The member has an underlying physical illness r injury; and The purpse f the assessment is nt fr the diagnsis r treatment f mental illness; and There is reasn t believe that bipsychscial factrs may be significantly affecting the medical treatment r medical management f an illness r injury; and The member is alert, riented and has the capacity t understand and t respnd meaningfully during the face-t-face encunter; and The member has a dcumented need fr psychlgical supprt in rder t successfully manage his/her physical illness and activities f daily living; and The assessment is nt duplicative f ther prvider assessments. H&B Reassessment (CPT cde 96151) Reassessment may be cnsidered reasnable and necessary when there has been a sufficient change in the member s mental r medical status warranting re-evaluatin f the member s capacity t understand and cperate with the necessary medical interventins (CMS LCDs, 2015). H&B Interventin Individual r Grup (CPT cdes 96152 and 96153) Specific psychlgical interventins and utcme gals have been clearly identified; and The psychlgical interventins are necessary t address: Nn-cmpliance with the medical treatment plan; and/r When bipsychscial factrs assciated with a newly diagnsed medical cnditin, r an exacerbatin f an established medical cnditin, affect symptm management and expressin, health-prmting behavirs, health-related risk-taking behavirs, and verall adjustment t medical illness; and The specific psychlgical interventins and utcme gals have been clearly identified. H&B Interventin with the Family and Member Present (CPT cde 96154) The family representative directly participates in the verall care f the member; and The psychlgical interventin with the member and family is necessary t address bipsychscial factrs affecting cmpliance with the medical plan f care, symptm management, health-prmting behavirs, health-related risk-taking behavirs, and verall adjustment t medical illness. Examples f H&B interventins include: Prviding infrmatin abut the member s medical cnditin and it s treatment; Prviding infrmatin abut the psychlgical, behaviral, emtinal, cgnitive, r scial factrs imprtant t the preventin, treatment r management f the member s medical cnditin; Caching the member t practice skills which will imprve self-management and participatin in treatment; Facilitating referrals t cmmunity resurces; Addressing medical treatment adherence r health risk-related behavirs; Adjustment t a newly diagnsed medical illness r a recent exacerbatin f symptms due t a medical diagnsis. Page 4 f 6
Clinical Best Practices Dcumentatin Requirements Because f the impact n the medical management f the member's disease, dcumentatin must shw evidence f crdinatin f care with the member's primary medical care prviders r medical prvider respnsible fr the medical management f the physical illness that the psychlgical assessment/interventin addresses (CMS LCD, 2015). Dcumentatin in the medical recrd must include: Evidence f a referral, fr the initial health and behavir assessment and fr each reassessment, by the medical prvider respnsible fr the medical management f the member s physical illness; Evidence f crdinatin f care with the member s primary medical care prviders r medical prvider respnsible fr the medical management f the physical illness that the psychlgical assessment/interventin was meant t address. Initial assessment (CPT cde 96150) Dcumentatin in the medical recrd must include evidence t supprt that the health and behavir assessment is reasnable and necessary, and must include, at a minimum, the fllwing elements: Date f initial diagnsis f physical illness; Clear ratinale fr why the health and behavir assessment is required; Assessment utcme including mental status and ability t understand and t respnd meaningfully; and Gals and expected duratin f specific psychlgical interventin(s), if recmmended. Reassessment (CPT cde 96151) Dcumentatin must include the fllwing elements: Date f change in mental r physical status; Clear ratinale fr why re-assessment is required, and Clear indicatin f the precipitating event that necessitates re-assessment. Interventin service, (CPT cde 96152 96154) Dcumentatin t supprt that the interventin is reasnable and necessary must include, at a minimum, the fllwing elements: Evidence that the member has the capacity t understand and t respnd meaningfully; Clearly defined psychlgical interventin plan and gals; The gals f the psychlgical interventin shuld clearly state hw the psychlgical interventin is expected t imprve cmpliance with the medical treatment plan; The respnse t the interventin must be indicated; Ratinale fr frequency and duratin f services; and The time duratin (stated in minutes) fr each visit spent in the health and behaviral assessment r interventin encunter. REFERENCES 1. Centers fr Medicare and Medicaid Services, Benefit Plicy Manual, 2014. Retrieved 5/22/17 frm www.cms.gv. 2. Centers fr Medicare and Medicaid Services, Lcal Cverage Determinatin, Health and Behavir Assessment and Interventin, L33834- First Cast Service Optins, Flrida, Puert Ric, Virgin Islands, retrieved 5/22/17 frm www.cms.gv. HISTORY/REVISION INFORMATION Date Octber, 2014 Versin 1 May, 2015 Versin 2 June, 2016 Versin 3 June, 2017 Versin 4 Actin/Descriptin Page 5 f 6
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