Section 35Psychologist 35 35.1 Enrollment...................................................... 35-2 35.1.1 STAR and STAR+PLUS Program Enrollment.......................... 35-2 35.2 Reimbursement.................................................. 35-2 35.3 Benefits and Limitations............................................ 35-2 35.3.1 Psychological and Neuropsychological Testing........................ 35-3 35.3.2 Therapy................................................... 35-4 35.4 Documentation Required........................................... 35-5 35.5 Claims Information................................................ 35-5 35.5.1 Claim Filing Resources........................................ 35-5
Section 35 35.1 Enrollment To enroll in the Texas Medicaid Program, a psychologist practicing independently must be licensed by the Texas State Board of Examiners of Psychologists and be enrolled as a Medicare provider. TMHP may waive the Medicare enrollment prerequisite for psychologists whose type of practice and service is pediatric-based and who will never bill to Medicare. A psychologist cannot be enrolled if his license is due to expire within 30 days. A current license must be submitted. Refer to: Provider Enrollment on page 2-2 for more information about enrollment procedures. 35.1.1 STAR and STAR+PLUS Program Enrollment Certain providers may be required to enroll with each STAR and STAR+PLUS health plan to be reimbursed for services provided to STAR and STAR+PLUS members. Contact the individual health plan for enrollment information. If the psychologist practices in the Dallas service area, he must be enrolled as a network provider in the NorthSTAR Behavioral Health Organization s (BHOs) network to provide services to NorthSTAR enrollees. Important: NorthSTAR is a pilot managed care program in the Dallas service area that covers behavioral health services. Providers must not bill TMHP for services rendered to NorthSTAR clients. 35.2 Reimbursement The Medicaid rates for psychologists are calculated in accordance with 1 TAC 355.8081 and 355.8085. The applicable Medicaid rates are listed in the 2004 Physician Fee Schedule (PRCR402C.xls), which is available on the TMHP website. A federally qualified health center (FQHC) is reimbursed according to its specific prospective payment System (PPS) rate per visit for psychological services. 35.3 Benefits and Limitations Psychologists licensed by the Texas State Board of Examiners of Psychologists and enrolled as Medicaid providers are authorized to perform counseling and testing for mental illness/debility. Treatment does not include the practice of medicine. Outpatient behavioral health services by a psychologist, for clients 21 years of age and older, are not a benefit of the Texas Medicaid Program, unless performed in an FQHC setting. Services will continue to be reimbursed for THSteps-eligible clients younger than 21 years of age. Psychologists must not bill for services performed by people under their supervision. For mental health services, only the provider actually performing the service may bill Medicaid. The services of a psychological associate (masters level psychologists), social worker, psychiatric nurse, or mental health worker are not covered by the Texas Medicaid Program and cannot be billed under a psychologist s TPI. Services provided by a licensed clinical social worker (LCSW), licensed professional counselor (LPC), or licensed marriage and family therapist (LMFT) are reimbursable directly to the LCSW, LPC, or LMFT. Outpatient mental health services are limited to 30 encounters per client, per calendar year (January 1 through December 31), regardless of provider unless prior authorization is obtained. This limitation includes encounters by all providers. An encounter is defined as each hour of therapy, psychological, and/or neuropsychological testing rendered per hour, per provider. Each Medicaid client is limited to 30 encounters per calendar year (January 1 through December 31). Laboratory, radiology, and medication monitoring services do not count toward the 30-encounter limitation. If a provider determines that additional services are medically necessary within the calendar year, prior authorization must be obtained before providing the 25th service. It is anticipated that this limitation, which allows for six months of weekly therapy or 12 months of biweekly therapy, will be adequate for 75 to 80 percent of clients. Clinicians should plan therapy with this limit in mind. However, it may be medically necessary for some clients to receive extended visits. In these situations, prior authorization is required. A provider who sees a client regularly and anticipates that the client will require visits beyond the 30-visit limit must submit the request for prior authorization before the client s 25th visit. It is recognized that a client may change providers in the middle of the year, and the new provider may not be able to obtain complete information on the client. In these instances, prior authorization may be made when the request is accompanied by an explanation as to why the provider was unable to submit the prior authorization request by the client s 25th visit and before rendering services. All authorization requests for extension of outpatient psychotherapy sessions beyond the annual 30-encounter limitation are limited to 10 visits/encounters per request, and must be submitted on the Extended Outpatient/ Counseling Request Form. Requests must include the following: Client name and Medicaid number Provider name and TPI Clinical update, including current symptoms and response to past treatment, and treatment plan (length of treatment, type of therapy, and frequency of visits) Prior authorization is not granted to providers who have seen a client for an extended period of time or from the start of the calendar year and who have not requested prior authorization before the 25th visit. It is recommended that a request for extension of outpatient behavioral health be submitted no sooner than 30 days before the date of service being requested, so that the most current information is provided. 35 2
Psychologist The number of visits authorized is dependent on the client s symptoms and response to past treatment. If the client requires additional extensions, the provider must submit a new request for prior authorization at the end of each extension period. The request for additional visits must include new documentation addressing the client s current condition, treatment plan, and the therapist s rationale supporting the medical necessity for these additional visits. Prior authorization for an extension of outpatient behavioral health services is granted when the treatment is mandated by the courts for court-ordered admissions. A copy of the court document must accompany prior authorization requests. Mail or fax the request to the following address: Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization 12357-B Riata Trace Parkway Austin, TX 78727 fax 1-512-514-4213 Medicaid does not cover treatment for chronic diagnoses such as mental retardation and organic brain syndrome. Psychiatric daycare is not a covered service. Refer to: Reimbursement Methodology on page 3-2 for more information about reimbursement methodologies. Managed Care on page G-1. Request for Extended Outpatient Psychotherapy/Counseling Form on page D-72. Licensed Clinical Social Worker (LCSW) on page 28-1. Licensed Professional Counselors (LPCs) on page 29-1. Licensed Marriage and Family Therapist (LMFT) on page 27-1 for more information. 35.3.1 Psychological and Neuropsychological Testing Procedure code 5-96100, Psychological testing, and 5-96117, Neuropsych test battery, are covered services for the following diagnoses only: Diagnosis Codes 0360 0369 317 7990 04500 0499 3180 3182 8500 85409 2900 2915 319 986 29189 2949 3200 3249 9941 29500 3029 3300 3319 99470 30390 30503 33392 V110 V119 30520 30583 340 V170 30591 30593 34500 34590 V400 V409 3080 3100 3480 3481 V6281 V6289 3101 430 4389 V7101 V7102 3102 7685 7686 V7109 Diagnosis Codes 3108 7721 7722 V790 V799 311 3149 7790 31500 3159 78031 78039 All claims for psychiatric procedure codes 1-90845, 1-90847, 1-90853, and 1-90857 referenced to the following diagnoses must include documentation supporting medical necessity. Procedure code 1-90801 billed with the following diagnoses does not require documentation: Diagnosis Code Description 2940 Amnestic syndrome 29410 Dementia in condition classified elsewhere without behavioral disturbance 29411 Dementia in condition classified elsewhere with behavioral disturbance 2948 Organic brain syndrome NEC 2949 Organic brain syndrome NOS When a psychologist performs psychological testing, procedure code 5-96100 must be billed. Procedure codes 5-96100, Psychological testing, and 5-96117, Neuropsych test battery, are limited to a quantity of four hours per day, per client, any provider. Each hour of therapy, psychological, and/or neuropsychological testing will count toward the 30 visits/encounters limit. Providers must maintain documentation of medical necessity for testing in the client s chart. Greater than four hours of psychological testing and neuropsychological testing battery will be cut back to a quantity of four when the medical necessity cannot be established. To document medical necessity, submit a record of all tests performed, and a complete history reflecting the need for each test. Procedure codes 5-96100, Psychological testing, and 5-96117, Neuropsych test battery, include the testing, interpretation, and report, and will not be reimbursed separately. Procedure code 5-96100, Psychological testing, will be limited to eight hours of testing per client, per calendar year, any provider. Procedure code 5-96117, Neuropsych test battery, will be denied when billed on the same day as procedure code 596100, Psychological testing, any provider. Procedure code 5-96100, Psychological testing, or 5-96117, Neuropsych test battery, is payable on the same day as procedure code 1-90801, Psy dx interview or 1-90802, Intac psy dx interview. 35 35 3
Section 35 Procedure code 5-96117, Neuropsych test battery, will be limited to eight hours per client, per calendar year, any provider. Example: If separate charges for an office visit and psychological testing, neuropsychological testing battery, or psychotherapy are billed on the same day, the office visit is denied as part of another procedure on the same day, unless the diagnosis referenced to the office visit indicates a physical condition unrelated to the psychiatric diagnosis. In this example, the office visit will be paid separately. The following is a list of psychiatric-related procedure codes: Procedure Code Description 1-90801 Psy dx interview 1-90802 Intac psy dx interview 1-90804 Psytx, office, 20-30 min 1-90806 Psytx, off, 45-50 min 1-90808 Psytx, office, 75-80 min 1-90810 Intac psytx, off, 20-30 min 1-90812 Intac psytx, off, 45-50 min 1-90814 Intac psytx, off, 75-80 min 1-90816 Psytx, hosp, 20-30 min 1-90818 Psytx, hosp, 45-50 min 1-90821 Psytx, hosp, 75-80 min 1-90823 Intac psytx, hosp, 20-30 min 1-90826 Intac psytx, hosp, 45-50 min 1-90828 Intac psytx, hosp, 75-80 min 1-90845 Psychoanalysis 1-90847 Family psytx w/patient 1-90853 Group psychotherapy 1-90857 Intac group psytx 35.3.2 Therapy When multiple counseling codes are billed by the same provider on the same day, only the most inclusive code will be paid. If procedure code 1-90801, Psy dx interview, or 1-90802, Intac psy dx interview, is billed on the same day as procedure codes 1-99221 through 1-99223, Initial hospital care, by the same provider, the initial hospital visit will be denied as part of another procedure on the same day. Procedure code 1-90802, Intac psy dx interview, billed on the same day as 1-90801, Psy dx interview, by the same provider will be denied as part of another procedure billed on the same day. If procedure code 1-90801, Psy dx interview, or 1-90802, Intac psy dx interview, is billed, procedure codes 1-90865, 1-90845, 1-90847, 1-90849, 1-90853, and 1-90804 through 1-90829, performed the same day, by the same provider, will be denied as part of the initial psychiatric exam. If procedure codes 1-90845, 1-90847, 1-90849, 1-90853, 1-90857, and 1-90816 through 1-90829, Intac psytx, hsp 75-80 w/e&m, are billed on the same day as procedure codes 1-99231, 1-99232, 1-99233, 1-99238, Subsequent hospital care, by the same provider, the subsequent hospital visit will be denied as part of another procedure billed on the same day. Procedure codes 1-99231, 1-99232, 1-99233, 1-90238, Subsequent hospital care, billed on the same day as shock therapy are not separately payable. Hospital subsequent care for diagnoses unrelated to the EST will be considered on appeal. The following procedure codes are not reimbursed by the Texas Medicaid Program: Procedure Code Description 1-90846 Family psytx w/o patient 1-90849 Multiple family group psytx When billing or providing procedure code 1-90847, Family psytx w/patient, note the following requirements for Medicaid reimbursement: The client must be present when family therapy/ counseling services are provided. Family therapy/counseling is only reimbursable for one family member per session. Counseling billed by a licensed psychologist will be coded 1-90847, 1-90853, 1-90857, 1-90804, 1-90806, 1-90808, 1-90810, 1-90812, 1-90814, 1-90816, 1-90818, 1-90821, 1-90823, 1-90826, and 1-90828. Psychoanalysis must be coded 1-90845. If procedure codes 1-90847, 1-90853 through 1-90857, and 1-90804 through 1-90829, Counseling, are billed on the same day as 1-90845, Psychoanalysis, counseling will be denied. When individual, group, or family counseling is billed by any provider on the same day, each type of session will be paid. When multiples of each type of session are billed, the most inclusive will be paid and the others will be denied. Counseling of less than 20 minutes duration must be reported using the appropriate evaluation and management code. When billing for contracted therapy services provided to Medicaid clients younger than 21 years of age residing in a residential treatment facility, use place of service (POS) 9 (other location). According to the definition of family provided by the Texas Department of Health and Human Services (HHSC) Household Determination Guidelines, only specific relatives are allowed to participate in family counseling services. These guidelines also address the roles of relatives in supervision and care of Temporary Assistance for Needy Families. The following specific relatives are included in family counseling services: Father or mother Grandfather or grandmother 35 4
Psychologist Brother or sister Uncle, aunt, nephew, or niece First cousin or first cousin once removed Stepfather, stepmother, stepbrother, or stepsister The following psychiatric services are not covered by the Texas Medicaid Program (except where specifically indicated in other sections): Services provided by a psychiatric nurse, mental health worker, or psychologist assistant Thermogenic therapy, recreational therapy, psychiatric daycare, and biofeedback, music or dance therapy Hypnosis Adult activity and individual activity (these types of services would be payable only if guidelines of group therapy are met and are termed group therapy) The following procedure codes are not a covered benefit for Texas Medicaid for any provider: Procedure Code Description 1-90846 Family psytx w/o patient 1-90849 Multiple family group psytx 35.4 Documentation Required Those services not supported by required documentation in the client's record will be subject to recoupment. Each client for whom services are billed must have the following documentation (which meets the standards indicated) included in their record: All entries are clearly documented and legible to individuals other than the author, date (month/day/ year), and signed by the performing provider. Notations of the beginning and ending session times. All pertinent information regarding the client s condition to substantiate the need for services, including but not limited to the following: Name of test(s) (e.g., WAIS-R, Rorschach, MMPI). Background and history of client and reason for testing. Behavioral observations during the session. Narrative description of the test findings. Diagnosis (symptoms, impressions). Treatment plan and recommendations. Explanation to substantiate the necessity of retesting. In addition to the above documentation requirements, the following (which meets the standards indicated) must be a part of each client s record for which services are billed: All entries are clearly documented and legible to individuals other than the author, date (month/day/ year), and signed by the performing provider. Notations of the beginning and ending session times. All pertinent information regarding the client s condition to substantiate the need for services, including, but not limited to, the following: Narrative description of the counseling session. Behavioral observations during the session. Narrative description of the assessment. Diagnosis (symptoms, impressions). Treatment plan and recommendations. 35.5 Claims Information Services provided by an independently practicing licensed psychologist must be submitted to TMHP in an approved electronic claims format or on a HCFA-1500 claim form. Providers must purchase HCFA-1500 claim forms from the vendor of their choice; TMHP does not supply them. 35.5.1 Claim Filing Resources Refer to the following sections and/or forms when filing claims: Resource Page Number HCFA-1500 Claim Filing Instructions 4-20 TMHP Electronic Claims Submission 4-11 Communication Guide A-1 Automated Inquiry System (AIS) User s B-1 Guide TMHP EDI General Information C-1 Psychiatric Hospital Inpatient D-67 Admission Form Request for Extended Outpatient D-72 Psychotherapy/Counseling Form Psychologist Claim Example F-28 Acronym Dictionary I-1 35 35 5