Fee-for-Service Provider Manual Non-PIHP Alcohol and Substance Abuse Community Based Services Updated 08.2015
PART II Introduction Section 7000 7010 8100 8200 8300 8400 Appendix BILLING INSTRUCTIONS Alcohol and Substance Abuse Community Based Services Billing Instructions... Specific Billing Instructions... Copayment... Medical Assessment... Benefit Plan... Medicaid... s... 7-1 7-2 8-1 8-2 8-3 8-4 A-1 FORMS All forms pertaining to this provider manual can be found on the public website and on the secure website under Pricing and Limitations. DISCLAIMER: This manual and all related materials are for the traditional Medicaid fee-for-service program only. For provider resources available through the KanCare managed care organizations, reference the KanCare website. Contact the specific health plan for managed care assistance. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information is available on the American Medical Association website.
PART II COMMUNITY BASED SERVICES Updated 08/15 This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to providers of alcohol and substance abuse community based services. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendix. The Billing Instructions subsection gives instructions for completing and submitting the billing form alcohol and substance abuse community based services providers must use when the beneficiary is not assigned to the Pre-paid Inpatient Health Plan (PIHP). If the beneficiary is assigned to the PIHP, contact ValueOptions at 1-866-645-8216. The Benefits and Limitations subsection defines specific aspects of the scope of alcohol and substance abuse community based services that are reimbursed by the Kansas Medical Assistance Program (KMAP). The Appendix subsection contains information concerning codes. Forms are on the public and secure websites. These forms can be duplicated for your use, except the sample claim forms. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R. 30-5-59 requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A. 21-3844 to 21-3855, inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations.
BILLING INSTRUCTIONS 7000. Updated 08/15 Introduction to the CMS 1500 and UB-04 Alcohol and substance abuse community based services providers must use the CMS 1500 or UB-04 paper or equivalent electronic claim form claim forms (unless submitting electronically) when requesting payment for medical services provided under KMAP. Claims can be submitted on the KMAP secure website or billed through Provider Electronic Solutions (PES). When a paper form is required, it must be submitted on an original red claim form and completed as indicated. Any CMS 1500 claim form not submitted on the red claim form will be returned to the provider. Examples of the CMS 1500 and UB-04 along with instructions are available on the KMAP public and secure websites on the Forms page under the Claims (Sample Forms and Instructions) heading in the Forms section at the end of this manual. Any of the following billing errors may cause a CMS 1500 paper claim to deny or be sent back to the provider: The Kansas MMIS uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information is not recognized unless submitted in the correct fields as instructed. Claim information must be submitted in the correct fields as instructed. Staples on the claim form. A CMS 1500 claim form carbon copy. The fiscal agent does not furnish the CMS 1500 claim form to providers. The interchange Medicaid Management Information System (MMIS) uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment. EDS does not furnish the CMS-1500 or UB-04 claim forms to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Complete, line-by-line instructions for completion of the UB-04 are available in the Hospital Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent PO Box 3571 Topeka, KS 66601-3571 BILLING INSTRUCTIONS 7-1
SPECIFIC BILLING INSTRUCTIONS 7010. Updated 08/15 Unit Billing The appendix provides code and time definitions for billing specific procedures (for example, 30 minutes, 1 hour). When billing according to this definition, bill one unit in field 24G. When billing for less than the amount of time indicated in the definition (less than one unit), bill as follows: ".25" represents one-quarter of the time specified. ".50" represents one-half of the time specified. ".75" represents three-fourths of the time specified. When billing for more than the amount of time indicated in the definition (more than one unit), bill as follows: "1.25" represents one and one-quarter units of the time specified. "1.50" represents one and one-half units of the time specified. "1.75" represents one and three-quarters units of the time specified. "2.00" represents two units of the time specified, and so forth. BILLING INSTRUCTIONS 7-2
8100. COPAYMENT Updated 08/15 Alcohol and substance abuse community based services are exempt from copayment requirements. 8-1
8200. MEDICAL ASSESSMENT Updated 08/15 The purpose of alcohol and drug assessment and referral is to determine the beneficiary s substance abuse treatment needs. If indicated, this may include the appropriate clinical placement for treatment or other referrals using the Kansas Client Placement Criteria (KCPC). The assessment and subsequent documentation must include factors pertaining to the beneficiary s emotional and physical health, social/family background, legal history, employment history, substance use/abuse, and prior treatments regarding any of the reported conditions. The KCPC may be administered only by approved center staff who have completed training on this placement/assessment instrument as evidenced by training certificates. Approved center staff is defined as clinical program staff members rendering Medicaidreimbursable services who are credentialed according to the State of Kansas, Addiction and Prevention Services Licensing Standards. To provide Medicaid-funded rehabilitation substance abuse treatment services, those services must be recommended by either a physician or other licensed practitioner of the healing arts as medically necessary to restore a beneficiary to his or her best possible functional level. A licensed mental health practitioner (LMHP) is an individual who is licensed in the State of Kansas to diagnose and treat mental illness or substance abuse acting within the scope of all applicable state laws and his or her professional licensure. An LMHP includes individuals licensed to practice independently such as: Licensed psychologist Licensed clinical marriage and family therapist Licensed clinical professional counselor Licensed specialist clinical social worker Licensed clinical psychotherapist An LMHP also includes individuals licensed to practice under supervision or direction: Licensed masters marriage and family therapist Licensed masters professional counselor Licensed masters social worker Licensed masters level psychologist Supervision or direction must be provided by a person who is eligible to provide Medicaid services and is licensed at the clinical level or is a physician. Another form of an other licensed practitioner is an advanced registered nurse practitioner (ARNP). An ARNP may be an eligible LMHP and can provide all services available to an LMHP that are within the ARNP s scope of practice. 8-2
8300. BENEFIT PLAN Updated 08/15 KMAP beneficiaries are assigned to one or more KMAP benefit plans. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification. For example, alcohol and substance abuse community based services are not covered for MediKan beneficiaries under KMAP. If the beneficiary is assigned to the PIHP, all alcohol and substance abuse services are the responsibility of the PIHP. For more information, contact ValueOptions at 1-866-645-8216. If the beneficiary resides in a psychiatric residential treatment facility (PRTF), all alcohol and drug abuse services are the responsibility of the PRTF. If the beneficiary is Title XXI, contact Cenpatico Behavioral Health at 1-866-896-7293. 8-3
8400. MEDICAID Updated 08/15 Enrolled alcohol and substance abuse providers must be licensed by the Kansas Department for Aging and Disability Services (KDADS) Social and Rehabilitation Services Addiction and Prevention Services (AAPS). Potential providers must complete the following steps, which will be verified in writing by AAPS prior to the enrollment application with the fiscal agent: Complete a computer questionnaire and security forms provided by AAPS to ensure there is sufficient hardware, software, and Internet access to meet the electronic data collection and reporting requirements Receive authorization from AAPS to download and install the KCPC system Provide evidence that clinical staff have attended an AAPS approved KCPC training After completion of the above steps, AAPS will issue a letter of approval and the potential provider will complete an enrollment application with the fiscal agent. Upon completion of the enrollment application with the fiscal agent, the potential provider will contact AAPS to ensure the process for electronic data collection has occurred. Only services described herein, determined to be medically necessary by ValueOptions-KS and provided by approved center staff in the manner described and in accordance with the beneficiary s individualized treatment plan, are reimbursable for alcohol and substance abuse community based services. General Charting Documentation Guidelines All clinical activity delivered in the course of treatment must be outlined in the individualized treatment plan with specific goals based on the assessment of medical necessity for treatment. This treatment plan is reviewed and updated regularly according to guidelines based on the beneficiary s assigned level of care. Documentation must show progress, be legible, and include, at a minimum, the following: Start and stop time Type of clinical activity Major issues covered from the treatment plan goals Complete date to include month, day, and year Staff providing the service and staff signature including credentials Progress notes related to the treatment plan goals 8-4
8400. MEDICAID Updated 08/15 Outpatient Outpatient counseling (behavioral health counseling and therapy or group counseling by a clinician) provides nonresidential alcohol and substance abuse treatment in an individual and/or group setting. Group outpatient counseling consists of counseling delivered in a group setting to two or more beneficiaries. Treatment must be based on an individualized treatment plan which is based on the assessment. This initial treatment plan must be completed within 30 days of the beneficiary s admittance into treatment and must be updated every 90 days. The provider must document every session. These outpatient services are limited to nine hours of scheduled counseling services each seven-day period. Peer support (PS) services are beneficiary centered services with a rehabilitation and recovery focus. These services are designed to promote skills to cope with and manage substance abuse symptoms while facilitating the use of natural resources and the enhancement of community living skills. Activities included must be intended to achieve the identified goals or objectives as set forth in the beneficiary s individualized treatment plan. The structured, scheduled activities provided by this service emphasize the opportunity for beneficiaries to support each other in the restoration and expansion of the skills and strategies necessary to move forward in recovery. PS is a face-to-face intervention with the beneficiary present. Services may be provided individually or in a group setting. The majority of PS contacts must occur in outpatient treatment centers and/or community locations where the beneficiary lives, works, attends school, and/or socializes. Provider must follow AAPS Peer Support Services Policy to provide these services. PS services will help the beneficiary to develop a network for information and support from others who have been through similar experiences. To bill for PS, submit the following codes: H0038 HF, PS Individual H0038HQ HF, PS Group Services are limited to no more than 12 units a day for each beneficiary. Crisis intervention (CI) services are provided to a beneficiary who is experiencing a substance abuse crisis. CI is designed to interrupt and/or ameliorate a crisis experience, including a preliminary screening, immediate crisis resolution and de-escalation, and referral and linkage to appropriate community services to avoid more restrictive levels of treatment. The goals of CI are symptom reduction, stabilization and restoration to a previous level of functioning. All activities must occur within the context of a potential or actual substance abuse crisis. CI is a face-to-face or telephonic intervention and may occur in a variety of locations, including emergency room or clinic setting, in addition to other community locations where the beneficiary lives, works, attends school, and/or socializes. This service may include the following components: 8-5
8400. MEDICAID Updated 08/15 A preliminary screening of risk, mental status, and medical stability and the need for further evaluation for other services Note: This includes contact with the beneficiary, family members or other collateral sources (such as caregiver or school personnel) with pertinent information for the purpose of a preliminary screening and/or referral to alternative services at an appropriate level. Short-term CI, including crisis resolution, debriefing, and follow-up with the beneficiary, and as necessary, with the beneficiary s caretaker and/or family members Consultation with a physician or with other providers to assist with the beneficiary s specific crisis Providers must follow AAPS Crisis Intervention Policy to provide this service. To bill for CI, submit code H0007. Case Management Case management means a one-on-one goal directed service for the substance abuse/dependent beneficiary through which the beneficiary is assisted in obtaining access to needed family, legal, medical, employment, educational, psychiatric, and other services. This service must be part of the treatment plan developed and determined medically necessary by ValueOption-KS. Case management services must be delivered by the program based upon the results of KCPC. The worker providing the service must at a minimum have: A high school degree with documented training in federal confidentiality guidelines as they relate to substance abuse At least two years experience working with substance abuse programs Supervision by an AAPS-credentialed substance abuse counselor Intensive Outpatient Intensive outpatient treatment (intensive outpatient) means treatment activities based on the individualized treatment plan where services are offered in regularly scheduled sessions throughout the week by approved center staff. Beneficiaries participate in structured therapeutic activities that may include alcohol and/or other substance abuse educational didactic groups, group counseling, and individual counseling. Intensive outpatient treatment consists of participating in services for a minimum of nine hours in a seven-day period. These minimum requirements must be met to be reimbursed for this level of service. This service must consist of services delivered at a minimum of three hours a day at least three days each week. These services must be based on an individualized treatment plan including assessment, counseling, crisis intervention, and activity therapies or education. In Kansas, it is only acceptable to bill for this service daily if the beneficiary participates in a minimum of nine hours of service in a seven-day period. 8-6
8400. MEDICAID Updated 08/15 Telemedicine Telemedicine is the use of communication equipment to link healthcare providers and patients in different locations. Healthcare providers use this technology for many reasons, including increased cost efficiency, reduced transportation expenses, improved patient access to specialist and substance abuse providers, improved quality of care, and better communication among providers. Substance abuse outpatient, assessment and case management services may be reimbursed when provided through telecommunication technology (excluding intensive outpatient treatment). The substance abuse treatment provider must bill the codes listed below using modifier GT (through interactive audio and video telecommunication systems) and are reimbursed at the same rate as face-to-face services. The originating site, with the beneficiary present, may bill code Q3014. H0001 GT, H0004 GT, H0005 GT, H0006 GT, H0007 GT, H0038 HF GT, H0038 HF HQ GT 8-7
APPENDIX Updated 08/15 CODES The following Current Procedureal Technology (CPT ) codes represent an all inclusive list of alcohol and substance abuse community based services billable for beneficiaries not assigned to PIHP. Procedures not listed here are considered noncovered. ASSESSMENT AND REFERRAL (KCPC SCREENING INSTRUMENT) H0001 One unit = one assessment OUTPATIENT INDIVIDUAL H0004 One unit = 15 minutes OUTPATIENT GROUP H0005 One unit = 15 minutes SUBSTANCE ABUSE CASE MANAGEMENT H0006 One unit = 15 minutes SUBSTANCE ABUSE CRISIS INTERVENTION H0007 One unit = 15 minutes INTENSIVE OUTPATIENT H0015 One unit = one day PEER SUPPORT INDIVIDUAL H0038 HF One unit = 15 minutes PEER SUPPORT GROUP H0038 HF HQ One unit = 15 minutes All above codes may be reimbursed (excluding H0015) with modifier GT for telemedicine. APPENDIX A-1