BEHAVIORAL

HEALTH PROVIDERS MEDICAID PROVIDER

VISITS SUMMER 2017

Brenda Stout

Medicaid Behavioral Health

Program Manager

TOPICS

Behavioral Health Cost Study

Next Steps

Documentation Standards

Key Definitions

Prior Authorization (a.k.a. Cap

Limits)

Provider Enrollment

Provider Contact Information

Retroactive enrollment

Applied Behavioral Analysis

Fee Schedule

Provider Manual

Questions

Contact Information

BEHAVIORAL HEALTH MEDICAID

COST STUDY

Overview

MEDICAID COST STUDY

Community Mental Health and Substance Abuse Treatment Centers

11 surveys received

Providers submitting surveys represent approximately 34% of all CMHC/SATCs but

60% of total CMHC/SATC payments

Independent/Group Practitioners

17 surveys received, 12 are “potentially usable” surveys

Providers submitting surveys represent approximately 4% of all independent/group

practitioners and 8% of total independent/group practitioner’s payments

PROVIDERS SUBMITTING A SURVEY BY COUNTY

78 percent of Wyoming

counties have a provider

that submitted a survey,

representing 83 percent

of Wyoming’s population

Both CPT and HCPCS are used for some services

HCPCS-based payment rates are not associated with professional level

Payment and units differ for the same therapy services based on use of HCPCS or CPT codes

Multiple HCPCS define the same service

Billed and allowed charges are the same for a large proportion of SFY 2016 line items

A large proportion of recipients received more than 20 days of service in SFY 2016

Unit billing for group therapy was more than expected in SFY 2016

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OBSERVATIONS REGARDING CURRENT

MEDICAID BH RATE STRUCTURE

PROPOSED CHANGES The billing/payment issues identified in the previous slides create

challenges in the development of accurate budget impacts at the State,

service and provider level. The following proposed changes are aimed at

standardizing billing and payment methodologies used

PR

OP

OS

ED

CH

AN

GE

Implement billing changes to simplify and streamline payment

• Reduce HCPCS code duplication

• Adjust provider taxonomies to recognize differences in provider licensure to distinguish between licensed and provisionally licensed professionals, and between Master’s level professionals and below Master’s level professionals

• Use state-specific modifiers to reflect provision of individual and family services in an agency-based versus community-based setting

RA

TIO

NA

LE

• Standardizes billing

• Reduces administrative burden on

state and providers

• Allows for more efficiency and

clear analysis of utilization and

expenditures by service, provider

and diagnosis code

PROPOSED CHANGES, CONT’D P

RO

PO

SE

D C

HA

NG

ES

Pay for assessment and therapy services using the Wyoming RBRVS methodology only (based on CPT code)

• Currently providers can choose between billing based on the HCPCS-based fee schedule or CPT-based RBRVS fee schedule.

RA

TIO

NA

LE

• Allows use of only one rate/payment

methodology for each service and is

consistent with Wyoming Medicaid’s

payment approach used for physicians

and other practitioners

• Reflects differences in resources needed

to provide different services

• Simplifies billing requirements

• Facilitates rate updates through

conversion factor

Adopt Medicare’s payment percentages

for professional level for assessment and

therapy services paid via RBRVS 100% -- Psychiatrists and psychologists

85% -- APRNs

75% -- LCSWs (apply to all other

professionals)

• Varies payment by level of education of

professional providing the service

• Provides consistency with Medicare

• Responds to provider concerns

BEHAVIORAL HEALTH MEDICAID

COST STUDY

Next Steps

ANTICIPATED CHANGES OVER THE NEXT TWO YEARS

Phase I – through Oct 1, 2017 July 1st – Implement limitations on group therapy and new modifiers for family

therapy and collateral contacts

Aug 1st – Implement consolidated behavioral health HCPCS procedure codes

Sept 1st – Implement BH documentation standards, WDH conducts provider visits

and webinar trainings

Oct 1st – Potentially implement BH prior authorization process to support “soft

cap” limit

Phase II – Oct 1, 2017 through 2018 Post Oct 1, 2017

Claims data reflects new billing requirements and prior authorization

process

Post Oct 1, 2018

• Analysis of new claims data

• Further identification of changes to the BH rate structure

Post Jan 1, 2019: Implementation

and monitoring of rate changes

(timing TBD)

10/1

2017

10/1

2018

12/1

2018

1/1

2019 2018 2019 2017 7/1

2017

PROPOSED HCPCS CODE CONSOLIDATION AND NEW MODIFIERS

Service Description Current HCPCS Consolidated HCPCS

Individual/family therapy Agency-based:

• H2019 – MH

• T007 – SA

Community-based

• H2021 – MH

• H0047 – SA

Individual Therapy:

H2019, with modifier TN if performed in a community-based

setting

Family Therapy:

H0004

Day treatment/psychosocial

rehab

H2017 – MH

T1012 – SA

H2017

Comprehensive Medication

Services

H0034 – MH

H2010 – SA

H2010

Group therapy H2019+HQ – MH

H0005 – SA

H2019+HQ

Individual rehabilitation H2014 – MH

H2015 – SA

H2014

Certified peer specialist H2014+HH – MH

H2015+HH – SA

H0038

Case management T1017 – MH

H0006 – SA

T1017, Adults, w/modifier HQ for group

G9012, Children (under 21), w/modifier HQ for group

Note: Providers must use new modifier UK when services

provided are on the behalf of the client to someone other

than the client (referred to as a Collateral Contact).

GROUP THERAPY LIMITATIONS

Three sessions per

day

2.5 hours (10 units)

per session

Maximum 15 clients per therapist

PRIOR AUTHORIZATION PROCESS

WDH is considering

implementation of an electronic

prior authorization system to

address soft cap on BH limits

Services exceeding 20 visits will

need to demonstrate medical

necessity to receive Medicaid

payment

Projected implementation date

will be October 1st, 2017

“Soft Cap” 20 Visit Limit on BH

• Applies to clients 21 years of

age or older

• Therapist must complete a

Behavioral Health Cap Limit

Waiver Request form to request

additional visits

• Additional services may be

available for clients over the age

of 21 served by the

Developmental Disabilities

Comprehensive or Supports

waiver

DOCUMENTATION STANDARDS

Requirements

BEHAVIORAL HEALTH DOCUMENTATION STANDARDS

1. Mental health assessment, diagnosis,

symptoms and identifying the clinical

needs of the client

2. Goals and objectives that address the

concerns of the client

3. Progress towards the identified goals and

objectives and notes

4. Treatment plan reviews and

assessment updates

The

Golden

Thread

WYOMING MEDICAID DOCUMENTATION

Implementation of documentation standards September 1st, 2017

Objectives

Incorporate the Golden Thread documentation standards

Educate providers on the importance of maintaining high quality records related to behavioral health services

Train Medicaid Behavioral Health Providers through webinars, provider visits, manuals, etc.

Many states in the nation use a standard practice for documenting behavioral health services. Washington, Ohio and Colorado use similar documentation rules called the Golden Thread, to assist providers with coding, billing and quality of care for the clients. With documentation rules, a provider will be able to explain services rendered, show medical necessity and maintain quality records for their clients.

DOCUMENTATION REQUIREMENTS

Wyoming Medicaid Rules, Chapter 3, Section 7 (b) states: "A provider

must have completed all required documentation, including required

signatures, before or at the time the provider submits a claim to the

Division. Documentation prepared or completed after the submission

will be deemed to be insufficient to substantiate the claim and Medicaid

funds shall be withheld or recovered."

Federal Regulations (42 CFR 431.107 (a), (b), (c)), Wyoming Medicaid

Rules (Chapter 3, Section 7 (c)) and the Medicaid Provider Participation

Agreement requires providers to furnish, upon request, medical records

involving services provided to Wyoming Medicaid clients.

THINGS TO REMEMBER WHEN DOCUMENTING

SERVICES PROVIDED TO MEDICAID CLIENTS: Always use ink (blue ink is preferred). DO NOT USE PENCIL!

NEVER use White-Out

DO NOT scribble through errors

Mark with a line and initial (i.e., 3:30 p.m. a.m. BKS)

Limit the use of abbreviations

Include the name of client and client Medicaid ID

Location of services

Date of service (include month, day, and year)

Name of service provided (use relevant, professional descriptions)

Keep dates and times in chronological order

Write down when timed services begin and when timed services end consistently using either a.m., p.m., or military time

Write down when timed services begin and when timed services end for each calendar day, even when services are provided over a period of longer than a calendar day

Signature of person performing service

If initials are used, a full signature must be included on each page of documentation

Detailed description of services provided

Document each service on separate forms or schedules

CHANGES TO DOCUMENTATION FOR BH SERVICES

Documentation of the services must contain the following:

Name of the client.

Identify the covered services provided and the procedure code billed to Medicaid.

Identify the date, length of time (start and end times in standard or military format), and location of the service.

Identify all persons involved.

Be legible and contain documentation that accurately describes the services rendered to the client and progress towards identified goals.

Full signature, including licensure or certification of the treating provider involved.

Providers shall not sign for a service prior to the service being completed.

No overlapping behavioral health services.

NOTE: When providing behavioral health services to a Medicaid client, the documentation must contain accurate dates and times the services were rendered (3.11 Record Keeping, Retention and Access, 13.9 Documentation Requirements for All Behavioral Health Providers). Behavioral health services cannot overlap date and time for a client. For example, a client being seen for group therapy on February 28th from 11:00 to 12:00 cannot also be seen for targeted case management on February 28th from 11:00 to 12:00. These are overlapping services and cannot be billed to Medicaid. The importance of proper documentation of services is important to differentiate the times of services being rendered, as you cannot bill times on a CMS 1500.

MEDICAID DEFINITIONS

REHABILITATIVE VS HABILITATIVE SERVICES

Wyoming Medicaid covers medically necessary therapy services, including mental health and substance abuse (behavioral health) treatment and physical, occupational, and speech therapy services via the federal authority guidelines granted by the Centers for Medicare and Medicaid Services (CMS) and specified in the Code of Federal Regulation's (CFR) rehabilitative services option section.

"Medical necessity" or "Medically necessary " means a determination that a health service is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected to relieve pain or to improve and preserve health and be essential to life. The service must be:

(A) Consistent with the diagnosis and treatment of the client's condition;

(B) In accordance with the standards of good medical practice among the provider's peer group;

(C) Required to meet the medical needs of the client and undertaken for reasons other than the convenience of the client and the provider; and,

(D) Performed in the most cost effective and appropriate setting required by the client's condition.

REHABILITATIVE SERVICES

Rehabilitative/Rehabilitation Services: Health care services that help you

keep, get back, or improve skills and functioning for daily living that have

been lost or impaired because you were sick, hurt, or disabled.

Services may include physical and occupational therapy, speech-language

pathology, and psychiatric rehabilitation services in a variety of inpatient

and/or outpatient settings.

HABILITATIVE SERVICES

Habilitative/Habilitation Services: Health care services that help you

keep, learn, or improve skills and functioning for daily living.

Examples include therapy for a child who isn't walking or talking at the expected age.

Services may include physical and occupational therapy, speech-language

pathology, and other services for people with disabilities in a variety of

inpatient and/or outpatient settings.

DISTINGUISHING BETWEEN HABILITATIVE

AND REHABILITATIVE SERVICES The key difference between the two definitions is whether you had the skill

or function.

Rehabilitative Services =If the person did have it and lost it due to a disease or

accident then it would be a rehabilitative service.

Habilitative Services = If the person never had it then it is a habilitative service.

Because Wyoming Medicaid is restricted to the reimbursement of services

that are exclusively rehabilitative and restorative in nature, the Medicaid

Developmental Disability Waiver Program (operating as the Comprehensive

and Supports Waiver in Wyoming) also includes coverage for habilitative

therapy services (physical, speech and occupational) beneficial to clients with a

developmental disability, recognizing that most often the services needed by

these clients are habilitative in nature, and do not meet the requirements of

the rehabilitative services covered by traditional Medicaid.

COLLATERAL CONTACT

Collateral contact is defined as an individual involved in the client’s care.

This individual may be a family member, guardian, healthcare

professional, or person who is a knowledgeable source of information

about the client’s situation and services to support or corroborate

information provided by the client. The individual contributes a direct

and exclusive benefit for the covered client.

Wyoming Medicaid Rules, Chapter 13, Mental Health Services, Section 3

(d).

PROVIDER ENROLLMENT

MEDICAID ENROLLMENT REQUIREMENTS

All Ordering, Referring, Prescribing (ORP), Attending and other Treating

Providers must be enrolled with Wyoming Medicaid.

Effective July 1st, 2016

Per ACA

Any claim submitted without the required ORP or attending physician information,

or submitted with information for a provider who is not enrolled with Medicaid, will

deny and the provider will not receive reimbursement for services.

Supervision of a Behavioral Health Provider

All providers must be enrolled with Wyoming Medicaid.

PROVIDER CONTACT INFORMATION

As enrolled providers, all providers are required to keep up to date

contact information on file with Wyoming Medicaid, including the

following:

Physical Address

Mailing Address for payment information

Mailing Address for correspondence

Phone number

Email address for notifications

Effective September 1st, 2016

PROVIDER CONTACT INFORMATION

Updates may be made by mail, fax, via the web portal Update Demographics (pay-to providers only), or the web portal Ask Medicaid option.

Wyoming Medicaid

Attn: Enrollment

P.O. Box 667

Cheyenne, WY 82003-0667

Phone: 1-800-251-1268

Fax: 307-772-8405

PROVIDER ENROLLMENT

Retroactive enrollments will not be allowed

Per the Affordable Care Act, Section 6401(a) and the Medicaid Provider Enrollment Compendium (MPEC)

Providers will be responsible for keeping their Medicaid enrollment current

Reenrollments will need to begin early enough that they are completed before there is a gap in active enrollment status

Policy is tentatively schedule to begin July 1, 2017

Emergency Retroactive Enrollment Criteria

The provider is out of state

The services are furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state practice location

The furnishing/treating provider is enrolled in an approved status in Medicare or in another state’s Medicaid plan on the date of service

The claim represents either a single instance of care furnished over 180 day period, or multiple instances of care furnished to a single participant, over a 180 day period

APPLIED BEHAVIOR ANALYSIS

TREATMENT

Overview

APPLIED BEHAVIOR ANALYSIS TREATMENT

The Centers for Medicare & Medicaid Services (CMS) is requesting that

states provide services to eligible individuals under the age of 21 years

with autism spectrum disorder (ASD). States should review their

current services for children with ASD and plan an approach to provide

medically necessary services to this population.

CMS Bulletin 7/7/2014

Wyoming Medicaid had 488 clients in State Fiscal Year (SFY) 2015 under

the age of 21 years with an Autism Spectrum Disorder or a pervasive

developmental disorder diagnosis (Wyoming Department of Health).

ABA SERVICES

Applied Behavior Analysis (ABA) treatments are allowable to children between the ages of 0-21 years of age with a diagnosis of Autism Spectrum Disorder.

Applied Behavior Analysis are individualized treatments based in behavioral sciences that focus on increasing positive behaviors and decreasing negative or interfering behaviors to improve a variety of well-defined skills.

ABA is a highly structured program that includes incidental teaching, intentional environmental modifications, and reinforcement techniques to produce socially significant improvement in human behavior.

ABA strategies include reinforcement, shaping, chaining of behaviors and other behavioral strategies to build specific targeted functional skills that are important for everyday life.

APPLIED BEHAVIOR ANALYSIS PROVIDERS Name Abbreviation and Requirements

http://bacb.com/credentials/

Board Certified

Behavior Analysts -

Doctoral

BCBA-D

Be actively certified as a BCBA in Good Standing

Have earned a degree from a doctoral program accredited by the Association for Behavior Analysis International

Or

A certificant whose doctoral training was primarily behavior-analytic in nature, but was not obtained from an ABAI-

accredited doctoral program, may qualify for the designation by demonstrating that his or her doctoral degree met the

following criteria:

(a.)The degree was conferred by an acceptable accredited institution; AND

(b.) The applicant conducted a behavior-analytic dissertation, including at least 1 experiment; AND

(c.) The applicant passed at least 2 behavior analytic courses as part of the doctoral program of study; AND

(d.) The applicant met all BCBA coursework requirements prior to receiving the doctoral degree.

Board Certified

Behavior Analysts

BCBA

Option 1 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate

coursework in behavior analysis, and a defined period of supervised practical experience to apply for the BCBA

examination.

Option 2 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate

coursework in behavior analysis that includes research and teaching, and supervised practical experience to apply for

BCBA examination.

Option 3 requires an acceptable doctoral degree that was conferred at least 10 years ago and at least 10 years post-

doctoral practical experience to apply for the BCBA examination.

APPLIED BEHAVIOR ANALYSIS PROVIDERS Name Abbreviation and Requirements

http://bacb.com/credentials/

Board Certified

Assistant Behavior

Analyst

BCaBA

1. Degree

Applicant must possess a minimum of a bachelor’s degree from an acceptable accredited institution. The bachelor’s degree

may be in any discipline.

2. Coursework

Course work must come from an acceptable institution and cover the required content outlined in the BACB’s Fourth

Edition Task List and Course Content Allocation documents.

3. Experience

Applicants must complete experience that fully complies with all of the current Experience Standards.

4. Examination

Applicants must take and pass the BCaBA examination.

Registered Behavior

Technician

RBT

1. Age and Education

RBT applicants must be at least 18 years of age and have demonstrated completion of high school or equivalent/higher.

2. Training Requirement

The 40-hour RBT training is not provided by the BACB but, rather, is developed and conducted by BACB certificants.

3. The RBT Competency Assessment

The RBT Competency Assessment is the basis for the initial and annual assessment requirements for the RBT credential.

4. Criminal Background Registry Check

To the extent permitted by law, a criminal background check and abuse registry check shall be conducted on each RBT

applicant no more than 45 days prior to submitting an application.

5. RBT Examination

All candidates who complete an RBT application on or after December 14, 2015 will need to take and pass an examination

before credential is awarded.

SERVICE CPT CODE

DESCRIPTION CPT® CODE BILLING

FREQUENCY

SERVICES PERFORMED

BY

Initial assessment (development of

initial treatment plan)

Behavior Identification assessment, by the physician or other

qualified health care professional, face-to-face with patient and

caregiver(s), includes administration of standardized and non-

standardized tests, detailed behavioral history, patient

observation and caregiver interview, interpretation of test

results, discussion of findings and recommendations with the

primary guardian(s)/caregiver(s), and preparation of report.

0359T (untimed

code)

Once per

authorization

period

Authorized ABA

supervisor

Observational behavioral follow-up

assessment for supervised field work

of assistant behavior analysts and

behavior technicians

Observational behavioral follow-up assessment includes physician

or other qualified health care professional direction with

interpretation and report, administered by one technician; first

30 minutes of technician time, face-to-face with the patient.

each additional 30 minutes of technician time, face-to-face with

the patient (List separately in addition to code for primary

service)

0360T (initial 30

minutes per day)

and 0361T (each

additional 30

minutes per day)

As applicable

Authorized ABA

supervisor or delegated

assistant behavior analyst

One-on-one ABA interventions

delivered per ABA treatment plan

protocol (direct hands-on ABA

services)

Adaptive behavior treatment by protocol, administered by

technician, face-to-face with one patient; first 30 minutes of

technician time.

each additional 30 minutes of technician time (List separately in

addition to code for primary procedure)

0364T (initial 30

minutes per day)

and 0365T (each

additional 30

minutes per day)

As applicable

Assistant behavior analyst

or behavior technician

under the tiered delivery

model, or by the

authorized ABA

supervisor under the sole

delivery model

One-on-one ABA intervention to

teach/implement a new or modified

technique from the treatment plan

Adaptive behavior treatment with protocol modification

administered by physician or other qualified health care

professional with one patient; first 30 minutes of patient face-to-

face time

each additional 30 minutes of patient face-to-face time (List

separately in addition to code for primary procedure)

0368T (initial 30

minutes per day)

and 0369T (each

additional 30

minutes per day)

As applicable

Authorized ABA

supervisor

Quarterly meetings between the

ABA supervisor, parents/caregivers

and assistant behavior

analysts/behavior technicians to

discuss treatment modifications

Quarterly

Transition or discharge

reassessments and treatment plan

updates

As applicable

Parent/caregiver(s) training

Family adaptive behavior treatment guidance, administered by

physician or other qualified health care professional (without the

patient present)

0370T

As applicable

Authorized ABA

supervisor or delegated

assistant behavior analyst

PROVIDER INFORMATION

Fee Schedule, Provider Manual, etc.

SPECIFIC CODES FOR CMHC/SATC

Only Community Mental Health Centers and Substance Abuse

Treatment Centers are allowed to bill the following services:

T1017 – Targeted Case Management

H2014/H2015 – Individual Rehabilitative Service

H2017/T1012 – Psychosocial Rehabilitation Services

Per Wyoming Medicaid Rules, Chapter 13 – Mental Health Services,

Section 6 (b)(i-xi)

Per State Plan Amendment, 3.1A 13D

CMS 1500 Provider Manual

CONTINUITY OF CARE DOCUMENT –

CCD VIEWER

Problems

Diagnosis

Family History

Immunizations

Vital Signs

Social History

Test Results

Medications

Procedures

Alerts

Allergies/Adverse Reactions

And more…

The CCD viewer allows authorized users to search for and retrieve a Patient Summary Continuity of Care Document (CCD) for current Medicaid clients. The CCD document is used to supplement the patient’s clinical health record.

The CCD is a HITSP standard patient summary document that contains all of the following information from the THR Gateway:

CCD VIEWER

To request THR CCD Viewer access, please send an e-mail containing: • Clinic Name • Address • Phone Number • Provider Names • Provider Email Addresses • Primary Contact To Andrea Bailey at: andrea.bailey@wyo.gov Visit the website at: http://wyomingthr.wyo.gov/ccd-viewer

FEE SCHEDULE

http://wyequalitycare.acs-inc.com/

Select Provider

Left Side of the Website, Select Fee Schedule

End User Agreement for Providers

Edit and Reimbursement Information

Coverage Indicator

Maximum Units of Service

Taxonomies Allowed

Taxonomy Percentages

Rate

PROCEDURE CODE SEARCH

PROVIDER MANUALS

CMS 1500 Provider Manual

Updated Quarterly

Behavioral Health Section

Documentation Requirements

Treatment Plan Requirements

Allowed Codes

Supervision

Community Mental Health & Substance Use Treatment Services Manual

Discontinued

PROVIDER RELATIONS (CONDUENT)

QUESTIONS?

Wyoming Medicaid will email provider bulletins announcing upcoming

changes and hold training sessions

Do you have more questions about the topics covered during today’s meeting?

Brenda Stout Medicaid Behavioral Health Manager

Wyoming Department of Health

Tel (307) 777-2896

brenda.stout1@wyo.gov