outpatient psychiatric and substance abuse services

DMAS Office of Behavioral Health

www.dmas.virginia.gov 1

Department of Medical Assistance Services

Outpatient Psychiatric and Substance Abuse Services

2013

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DisclaimerThese slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations.

*Please refer to the manual, available on the DMAS website portal, for in-depth information on Psychiatric Services criteria. Providers are responsible for adhering to related state and federal regulations.

www.vita.virginia.govwww.dmas.virginia.gov 2


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Outpatient Psychiatric and Substance Abuse

Objectives of this Training Are:

• To define the criteria of Outpatient Psychiatric and Substance Abuse Services

• To identify staff qualifications;• To clarify eligibility criteria;• To identify required activities;• To review limitations of the service; • To review criteria for discharge• To review telemedicine criteria• To outline service units and reimbursement; and• To review service authorization requirements.






Outpatient Psychiatric and Substance Abuse Service Definition

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• Medically prescribed treatment that is directly and specifically related to an active written plan designed and signature-dated by either a psychiatrist or by a licensed clinical social worker, licensed professional counselor, licensed clinical nurse specialist-psychiatric, or licensed marriage and family therapist. These individuals may either provide services in a mental health clinic under the direction of a psychiatrist or enroll directly as Medicaid providers.

• Outpatient psychiatric and substance abuse services are provided in a practitioner’s office, mental health clinic, patient’s home, or nursing facility.







Licensing

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Outpatient Psychiatric and Substance Abuse providers must have a Department of Behavioral Health and Developmental Services (DBHDS) license to provide Outpatient Mental Health or Outpatient Substance Abuse Services.







Staff Qualifications

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Psychiatric services may be provided by psychiatrists or by a licensed clinical social worker, licensed professional counselor, licensed clinical nurse specialist-psychiatric, or a licensed marriage and family therapist under the direct supervision of a psychiatrist. Services may also be supervised by a psychologist.

The above listed may also be directly enrolled with Medicaid and shall operate within the scope of their license.



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Outpatient substance abuse services may be provided by medical doctors or by doctors of osteopathy who have completed three years of post-graduate residency training in psychiatry; or by a physician or doctor of osteopathy who is certified in addiction medicine.

The provider must also be qualified by training and experience in all of the following areas of substance abuse/addiction counseling: clinical evaluation; treatment planning; referral; service coordination; counseling; client, family, and community education; documentation; and professional and ethical responsibilities.



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Outpatient substance abuse services may also be provided by a licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed psychiatric clinical nurse specialist, a licensed psychiatric nurse practitioner, a licensed marriage and family therapist, a licensed substance abuse treatment practitioner, or an individual who holds a bachelor's degree and certification as a substance abuse counselor (CSAC) who is under the direct supervision of one of the licensed practitioners listed in this section, or an individual who holds a bachelor's degree and is a certified addictions counselor (CAC) who is under the direct supervision of one of the licensed practitioners listed in this section.



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The substance abuse provider must also be qualified in all of the following areas of substance abuse/addiction counseling:

– clinical evaluation;– treatment planning; – referral; – service coordination; – counseling; – client, family, and community education; – documentation; and – professional and ethical responsibilities.



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If a psychotherapy session is rendered by an unlicensed therapist, and under the direct, personal supervision of a qualified, Medicaid enrolled provider, the therapy session must contain not only the dated signature of the therapist rendering the service but also the dated signature of the supervising provider. Each therapy session must contain the co-signature of the supervising provider on the date the service was rendered indicating that he or she has reviewed the note.

If the regular supervisor is not present in the facility on the day the service is rendered any licensed therapist present on that day may review and sign the note.






Outpatient Psychiatric and Substance Abuse Eligibility Criteria

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• In order for an individual to receive outpatient psychiatric and/or substance abuse services they must meet ALL of the following:

1. Require treatment in order to sustain behavioral or emotional gains or to restore cognitive functional levels, which have been impaired;

2. Exhibit deficits in peer relations, dealing with authority, hyperactivity, impulse control, clinical depression, or demonstrates other dysfunctional symptoms having an adverse impact on attention and concentration, the ability to learn, or the ability to participate in employment, educational, or social activities;



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3. Is at risk for developing or requires treatment for maladaptive coping strategies; and

4. Presents a reduction in individual adaptive and coping mechanism or demonstrates extreme increase in personal distress.

• For Substance Abuse services, individuals must meet the Diagnostic Statistical Manual of Mental Disorders (DSM) (most recent version) diagnostic criteria for an Axis I Substance Use Disorder, with the exception of nicotine or caffeine abuse or dependence, including Tobacco Use.



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• The Axis I substance-related disorder shall meet American Society of Addiction Medicine (ASAM) Level of Care Criteria as prescribed in Patient Placement Criteria for the Treatment of Substance-Related Disorders.

• The ASAM assessment must be completed prior to the start of services and must support the need for this level of service.– Two substance abuse screening codes, 99408 and 99409 are

eligible for reimbursement and do not require service authorization.






Outpatient Psychiatric and Substance Abuse Required Activities

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• Completion of a history/assessment must be conducted at the initiation of services and must include:

– The onset of the diagnosis and functional limitations;– Family dynamics; ability/desire of the family/caretakers to

participate and follow through with treatment;– Areas that may require consideration (foster care, family

dysfunction);– Previous treatment and outcomes; – Medications, current and history of;– Medical history if relative to current treatment;– Treatment received through other programs (Sp. Ed.,

Community Services Board, etc)– Mental Status



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• Services must be medically prescribed treatment that is directly and specifically related to an active written plan designed by a Licensed Mental Health Professional (LMHP).

• An initial plan of care must be completed, signed and dated by a qualified provider (LMHP) at the time of prior authorization.

• Focus of the plan of care must be related to the diagnosis and include all of the following:

• Individual specific goals related to symptoms and behaviors.• Treatment modalities that will be used and documentation

specific to the appropriateness of the modalities (why the modality was chosen for this individual)



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• Estimated length that treatment will be needed.• Frequency of the treatments/duration of the treatment• Documentation of the family/caregiver participation

• The plan of care must be reviewed by the provider every 90 days or every sixth session, whichever time frame is shorter, from the date of the provider’s signature.

• The review may be incorporated into the progress notes, however must be identifiable as a review of the plan of care and address any changes such as:

• Relapse and/or changes in symptoms/behavior• Changes in environment• Risk for higher level of care, etc



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• A separate plan of care is required for psychiatric services and substance abuse services when prior authorization is requested separately.

• The primary diagnosis should indicate the focus of treatment.

• If the individual has co-occurring mental health and substance use disorders, integrated treatment for both disorders is allowed with the expectation that the clinician will bill for the primary presenting problem.



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• The psychiatric services sessions are separate from the substance abuse treatment sessions if the clinician requests separate authorizations.

• If services are provided in a setting other than the office or a clinic, this must be documented.

• Evidence of coordination with the Primary Care Physician (PCP), if applicable, or documentation that it is not applicable must be documented. The purpose of the evaluation/coordination is to rule out any underlying medical conditions that may be causing the symptoms.



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• Progress notes for each session must be specific to the individual and include the following:

– A description of how the activities in the session relate to the individual’s goals

– A description of the therapeutic interventions– The length of the session– The level of participation in treatment by the individual– The modalities of treatment (i.e. talk therapy, play therapy, etc)– The type of session (group, individual, medication management, etc)– The Individual’s progress or lack thereof toward goals– The plan for the next treatment session– Date and signature of provider– Evidence of discharge planning







Limitations

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• Individual, family, and group psychotherapy and substance abuse services are limited to no more than three sessions in a seven day period.

• Substance Abuse (SA) treatment sessions are separate from psychiatric services. When medically necessary, there may be concurrent authorizations for SA and psychiatric services. Providers are encouraged to integrate treatment when there is a co-occurring condition.

• If the service limit of three sessions in a seven day period will be exceeded another level of service may be more appropriate such as SA Intensive Outpatient or SA Day Treatment.



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• There is an annual limit of 3 substance abuse screening (99408/99409) per calendar year, per provider per individual.

• CPT codes 90832 through 90838, 90846, 90847, 90853, and 90853 with the 90755 add-on are codes designated for substance abuse services with the HF modifier.

• Substance Abuse Treatment Practitioners are only eligible to provide CPT codes with HF modifiers, excluding the evaluation and management codes.



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• CPT codes 90792, 90833, 90836, 90838 are to be billed with the appropriate evaluation and management CPT codes and may only be used by physicians.

• Psychological and neuropsychological testing are allowed when done for purposes other than educational diagnosis, school admission, evaluation of an individual with intellectual disabilities prior to admission to a nursing facility, or any placement issue.

• One psychological or neuropsychological test is allowed per six month period and up to seven hours of units.

• Testing does not require service authorization.www.vita.virginia.govwww.dmas.virginia.gov 28


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• Individual therapy is limited to one session per day.

• Group therapy is limited to one session per day.

• Services for sensory stimulation, recreational activities, art classes, excursions, or eating together are not included as group therapy.

• There is a maximum of 10 individuals per group session.

• Groups are expected to be held for a minimum of 30 minutes.



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• Family therapy is limited to one session per day and is expected to be held for a minimum of 30 minutes.

• Multiple-family group therapy is a non-covered service.

• Separate payment is allowed for the attending physician and the anesthesiologist involved in electroconvulsive therapy.

• Medication management must be fully documented and medically necessary and is limited to 4 sessions per month. Service authorization is not required.



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• The psychiatric diagnostic interview, 90791 or 90792, is limited to once per year per provider per individual and does not require service authorization.

• The psychiatric diagnostic interview may include a review of records or reports, communication with family or other sources, and interpretation of lab work or other medical diagnostic studies.

Non-Covered Psychiatric and Substance Abuse Services include:

– Broken appointments

– Remedial educationwww.vita.virginia.govwww.dmas.virginia.gov 31


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Outpatient Psychiatric and Substance AbuseNon-Covered Services Continued:

– Day care

– Psychological testing done for purposes of educational diagnosis or school admission or placement

– Occupational therapy

– Teaching “grooming” skills, monitoring ADLs, bibliotherapy, reminiscence therapy, or social interaction

– Telephone consultations

– Mail order prescriptions

– Psycho-education for the purpose of educating the individual's guardian about the diagnosis and related symptoms or treatmentwww.vita.virginia.govwww.dmas.virginia.gov 32


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Non-Covered Services Continued:

– Any procedure considered experimental

– Teaching parenting skills

– Case management as part of outpatient therapy services

– Treatment team meetings

– Interpretation of examinations, procedures and data, and the preparation of reports. This includes CPT code 90885 (psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes).

– Medical hypnotherapy and environmental interventionwww.vita.virginia.govwww.dmas.virginia.gov 33





Outpatient Psychiatric and Substance Abuse Discharge Criteria

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Outpatient Psychiatric and Substance AbuseDischarge criteria for substance abuse services for

adults:

• After completion of 12 months of treatment, the individual should be discharged from active treatment if the following criteria are met:

– No active cravings for illegal substances that impact Activities of Daily Living (ADLs)

– No current preoccupations with getting high or past drugging experiences that impact ADLs

– Minimal or manageable guilt, remorse, and/or shame– No drug seeking behaviors– No drug glorification that impacts ADLs– Has attended 80% or more of the scheduled

individual/group/family therapy sessions in the past monthwww.vita.virginia.govwww.dmas.virginia.gov 35


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– Has no uncontrolled abusive or addictive behaviors at home, at work or in peer interactions.

– Has had no positive drug screens or positive breathalyzer tests in the last 6 months

– Has family/peer connections that support sobriety

If the above are met the individual is eligible to enter into a relapse prevention phase of treatment for an additional 6 months, to include:

– One session of individual or group therapy every 2 weeks– Random urine or breathalyzer monitoring at least twice in 6

months– Encourage attendance at 12-step programs



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Outpatient Psychiatric and Substance AbuseDischarge criteria for substance abuse services for

adolescents:

• After completion of 12 months of treatment, the individual should be discharged from active treatment if the following criteria are met:

– No active cravings for illegal substances that impact Activities of Daily Living (ADLs)

– No current preoccupations with getting high or past drugging experiences that impact ADLs

– Minimal or manageable guilt, remorse, and/or shame– No drug seeking behaviors– No reckless or acting out behaviors directly related to SA– Has attended 80% or more of the scheduled

individual/group/family therapy sessions in the past monthwww.vita.virginia.govwww.dmas.virginia.gov 37


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– Has no uncontrolled abusive or addictive behaviors at school or in social life

– Has had no positive drug screens or positive breathalyzer tests in the last 6 months

– Has family/peer connections that support sobriety

If the above are met the individual is eligible to enter into a relapse prevention phase of treatment for an additional 6 months, to include:

– One session of individual or group therapy every 2 weeks– Random urine or breathalyzer monitoring at least twice in 6

months– Encourage attendance at 12-step programs







Telemedicine

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• Telemedicine is the real-time two-way transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment.

• The Medicaid recipient is located with a provider at the “originating” site, while the “remote” provider renders services via the audio/video connection.

• All telemedicine providers must be enrolled with DMAS.

• Equipment utilized for telemedicine must be of sufficient audio quality and visual clarity as to be functionally equivalent to a face-to-face encounter for professional medical services.



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• Telemedicine services do not include telephone conversations or Internet e-mail communications between providers or providers and recipients and does not include the use of Skype.

• Providers must be physically present in Virginia during the telemedicine encounter.

• Reimbursement for telemedicine services is the same as when the services are delivered conventionally.

• DMAS does not cover services via Telemedicine beyond what is described in the provider manuals.

• Services billed where telemedicine is the mode of service delivery but the claim form and service documentation do not indicate telemedicine, are subject to disallowances in the course of an audit.



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• The following behavioral health service codes are eligible to use telemedicine:– CPT 99408 and 99409; substance abuse screening and brief

interventions– H0036; crisis intervention (mental health)– H0050 with HO procedure modifier; crisis intervention

(substance abuse)– CPT 90791 and 90792; psychiatric diagnostic interview

examination– CPT 90832-90834 and 90836-90838; individual psychotherapy– CPT 90863; pharmacologic management

* For other medical codes see the Medicaid memo on Telemedicine dated 09/30/2009



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• The following types of providers enrolled with DMAS may utilize telemedicine for the above services when the service delivered by the type of provider is covered by DMAS:

– physicians, – nurse practitioners, – clinical nurse specialists, – clinical psychologists, – clinical social workers, – licensed professional counselors, – licensed marriage and family therapists, and – licensed substance abuse practitioners.



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• The “originating” sites, where the Medicaid recipient is located for the telemedicine encounter, have been expanded to include the following:

– Physician, – Nurse Practitioner, – Clinical Nurse Specialist, – Clinical Psychologist, – Clinical Social Worker, – Licensed Professional Counselor, – Licensed Marriage and Family Therapist, and – Licensed Substance Abuse Practitioner Offices;



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“Originating” Sites Continued:– Rural Health Clinics; – Federally Qualified Health Centers; – Hospitals (includes general, state mental, private mental, long

stay, rehabilitation);– Nursing Facilities (includes skilled nursing, medical surgery-

intellectual disability, intermediate care); – Certified Outpatient Rehabilitation Facilities; – Health Department Clinics; – Renal Units (dialysis centers); – Program of All Inclusive Care for the Elderly (PACE); and – Community Services Boards (mental health/intellectual

disability provider) and Mental Health Clinics.



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• The originating site providers bill the Q3014 telemedicine site procedure code for the telemedicine encounter.

• Providers billing telemedicine on the CMS-1500 form must include the “GT” telemedicine modifier.

• Providers billing on the CMS-1450 UB-04 form are to include the appropriate telemedicine revenue code of 0780 (“Telemedicine-General”) or 0789 (“Telemedicine-Other”).

• Telemedicine encounters must be conducted in a confidential manner and any information sharing consistent with applicable federal and state laws and regulations and DMAS policy. Health Information Portability and Accountability Act of 1996 (HIPPA) confidentiality requirements are applicable to telemedicine encounters.







Units and Reimbursement

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• The initial 26 sessions can be used within one year of the date of the first date of service (anniversary date) and cannot be carried over into subsequent years.

• An additional 26 sessions may be used in the first year of service with prior authorization.

• There is a limit of 26 sessions in subsequent years. All of those sessions must be prior authorized.

• The 26-session limit does not apply to the diagnostic interview examination.

• If the service limit is met for individuals under the age of 21, additional sessions are available through the EPSDT program and must be prior authorized.



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• Physician fees are based on Resource Based Relative Value Scale (RBRVS) for specific CPT code.

• Services of a licensed clinical psychologist are reimbursed at 90% of the reimbursement rate for psychiatrists.

• Services provided by independently enrolled licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, psychiatric nurse practitioners, licensed substance abuse treatment practitioner, or licensed clinical nurse specialists‑psychiatric shall be reimbursed at 75% of the reimbursement rate for licensed clinical psychologists.







Service Authorization

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• Authorization is required after 26 sessions in the first year of treatment.

• During the first years there may be an additional 26 sessions when prior authorized.

• The initial 26 sessions can be used within one year of the date of the first date of service (anniversary date) and cannot be carried over into subsequent years.



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• To check whether authorization is required for additional psychiatric services providers may access the Automated Response System (AS) through the internet, or access the MediCall ARS by telephone.

• Detailed information on the use of ARS and MediCall ARS is available in Chapter 1 of the Psychiatric Services Manual.



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KePRO is the DMAS contractor for Service Authorization (SA). For questions go to the SA website:

DMAS.KePRO.org and click on Virginia Medicaid

Phone: 1-888-VAPAUTH or 1-888-827-2884

Fax: 1-877-OKBYFAX or 1-877-652-9329

Web: [email protected] or

[email protected]



mailto:[email protected]


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Submitting a request

• The preferred method is through the Atrezzo® web-based program

• Registration is required

• Information on Atrezzo is available on the KePRO website, or call 1-888-827-2884 or (804) 622-8900 or mail to:

» KePro» 2810 North Parham Rd, Suite 305» Henrico, Virginia 23294



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• For Outpatient Psychiatric Services KePRO will apply McKesson InterQual® Behavioral Health Psychiatry Level of Care Criteria, as well as DMAS supplemental eligibility criteria to determine medical necessity for the service.

• For Outpatient Substance Abuse Services KePRO will apply McKesson InterQual® Behavioral Health Chemical Dependency & Dual Diagnosis Level of Care Criteria, as well as DMAS supplemental eligibility criteria to determine medical necessity for the service.



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Requests Should Include:• Dates of service being requested• CPT codes to indicate type of outpatient service

(psychiatric, SA, group, individual, etc)• A DSM diagnosis• Enough clinical information with examples to indicate

eligibility criteria listed in this training has been met.Once authorization is obtained, if the individual is discharged from the service and there are dates of service and units that have not been used, please contact KePRO to notify of discharge so that remaining dates may be available at a later time by another provider.



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• Many Medicaid recipients are enrolled with one of the Departments contracted Managed Care Organizations (MCO).

• For an MCO enrolled individual providers must contact and follow the MCO’s contract.

• The MCO may utilize different service authorization, billing, and reimbursement guidelines than those described in this training.

• For more information providers may contact the MCO directly or find additional information about the Medicaid MCO program at:

http://www.dmas.virginia.gov/mc-medallionII.htm.



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Helpful Resources:

• Virginia Medicaid Web Portal link www.virginiamedicaid.dmas.virginia.gov

• DMAS Office of Behavioral Health:– Email Address [email protected]

• DMAS Helpline: 804-786-6273 Richmond Area1-800-552-8627 All other



http://www.virginiamedicaid.dmas.virginia.gov/


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Thank you for attending this training and helping to serve Virginia’s Medicaid Recipients.



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