ATTENTION:
Effective January 1, 2002, this contract will encompass all elective and emergency admission reviews, concurrent continued stay reviews, and post discharge reviews when applicable.
Registration information for seminars and a list of the seminar sites has been mailed to all enrolled providers. These seminars are scheduled for early December 2001.
Copies of ValueOptions’ utilization review manual, which provides more detailed information on procedures, will be available at the seminars.
This article is reprinted and modified from the June 2000 general Medicaid bulletin where it was titled A New Health Benefit.
Effective July 1, 2000, a new preventive/early intervention mental health benefit was made available to approximately 400,000 state employees and teachers and 60,000 children enrolled in Health Choice. Medicaid adopted this policy for recipients under the age of 21, which allows for 26 unmanaged visits in a calendar year.
Prior approval forms can be obtained by calling ValueOptions at 1-888-510-1150.
Effective January 1, 2002, Medicaid recipients aged 21 and over receiving outpatient mental health services will require prior approval after the 8th visit. This includes area mental health programs and private providers. This process replaces the policy of requesting prior approval after the 2nd visit for non-area mental health programs.
The 24-office visit limitation per year is removed and replaced by the requirement for prior approval after the 8th visit for mental health services subject to independent utilization review. Approval will be based on medical necessity.
Billing Guidelines
These visits can be counted in a number of ways. Each individual visit
is counted as one visit; each group visit is counted as one-half visit.
Group codes that will be involved are Y2306, 90846, 90847, 90849, 90853,
and 90857.
Individual codes that will be counted as one visit are Y2305, Y2306, 90801 through 90853 and 96100 through 96117.
Prior approval forms can be obtained by calling ValueOptions at 1-888-510-1150.
This article is reprinted from the August 2000 general Medicaid bulletin. Note: The "incident to service" policy applies to recipients of all ages. The prior approval process referenced below is for recipients under the age of 21.
Effective August 1, 2000, the Division of Medical Assistance (DMA) has expanded the "incident to service" policy to include Licensed Clinical Social Workers (LCSW) and Advanced Practice Psychiatric Clinical Nurse Specialists (CNS) who are masters level registered nurses with psychiatric certification in providing mental health/substance abuse services. The LCSWs and CNSs must be employed by the supervising physician, physician group practice or of the legal entity that employs the physician who provides direct personal supervision. (Refer to the article concerning the incident to service policy in the July 1997 general Medicaid bulletin for additional information.)
Licensed Psychological Associates
This article is reprinted and modified from the May 2001 general Medicaid bulletin. Note: This "incident to service" extension only applies to services for recipients under 21 years of age by the Licensed Psychological Associate (LPA).
Effective August 1, 2000, DMA has expanded the "incident to service" policy to include LCSWs and CNSs who are masters level registered nurses with psychiatric certification in providing mental health/substance abuse services. The LCSW and CNS must be an employee of the supervising physician, physician group practice or of the legal entity that employs the physician who provides direct personal supervision.
Effective June 1, 2001, this policy is further expanded to allow LPAs to bill for services "incident to" if they are supervised and employed by Ph.D. psychologists or, as is currently the case, physicians.
The benefit package includes 26 outpatient visits per calendar year when referred by the Carolina ACCESS (CA) primary care physician (PCP) or area mental health programs. Visits beyond the 26-visit limit will require the mental health provider to request prior authorization from Value-Options, the utilization review organization.
As the referring provider, the CA PCP or area mental health program will give the mental health provider a referral number for payment of the claim. The mental health provider cannot be paid unless the referring provider’s number appears on the claim. To facilitate the referral process, referrals may be made by telephone, fax, or in writing. Mental health providers are expected to communicate the plan of care and anticipated length of treatment to the referring provider following the guidelines for patient confidentiality as a means to assure continuity of care.
Hospitals admitting a patient, who is neither Medicaid eligible on or before admission, nor pending eligibility, but applies for Medicaid during a psychiatric hospitalization, must send in the entire medical record to ValueOptions within 30 days of discharge. ValueOptions will perform a post discharge review to determine prior approval for medically necessary days of acute care.
A phone call to ValueOptions will no longer be necessary for patients who apply for Medicaid during or after the stay. Hospitals must obtain a Medicaid identification (MID) number for the patient and send it to ValueOptions along with the medical record.
In addition to the MID number, if the patient is a child or adolescent admitted to a psychiatric hospital, a Certification of Need (CON) form must also be sent to ValueOptions. Due to difficulties in being able to meet the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) requirements for performing a CON "on or before the Medicaid application date" and realizing that hospitals may have problems receiving notification of a patient’s application for Medicaid, DMA suggests that a CON be performed and immediately submitted to ValueOptions on every child or adolescent admission to a psychiatric hospital, regardless of Medicaid status on admission. ValueOptions will place the CON in a holding file if the form indicates the patient has yet to apply for Medicaid. If a patient applies for Medicaid on or after the discharge date, the hospital must still send the entire medical record to ValueOptions for review with the CON (if applicable) and the MID number.
Once eligibility has been verified, it will be determined by ValueOptions whether days were medically necessary. ValueOptions will send a notification letter to the hospital stating approval or denial of acute care days. Any approval will include a prior approval number.
If eligibility verification reflects the Medicaid application occurred on or before admission rather than during the stay as reported, the hospital stay will not be reviewed. For any patient already eligible or pending eligibility on admission, the hospital must still request telephone prior approval from ValueOptions within 48 working hours of admission and continue with the concurrent review process.
Refer to the following section of the N.C. Administrative code for psychiatric admission criteria for recipients under the age of 21.
N.C. Administrative Code 10T: 26B.0112
Criteria for Continued Stay in an Inpatient Psychiatric Facility
Refer to the following section of the N.C. Administrative code for continued stay criteria for individuals under the age of 21 in a psychiatric hospital or in a psychiatric unit of a general hospital, and to individuals aged 21 through 64 receiving treatment in a psychiatric unit of a general hospital.
N.C. Administrative Code 10T: 26B.0113
Hospitals admitting a patient who is neither Medicaid-eligible on or before admission, nor pending eligibility, but applies for Medicaid during a psychiatric hospitalization, must send in the entire medical record to ValueOptions for psychiatric review within 30 days of discharge. If a patient applies for Medicaid after hospital discharge, the complete medical record must be sent to ValueOptions within four months of the patient’s Medicaid application date. It is the facility’s responsibility to make sure the record is mailed within this time frame. ValueOptions will perform a post discharge review to determine prior approval for medically necessary days of acute care if the record arrives at their place of business on time. A medical record received after the deadline will not be reviewed.
All other aspects of the September 2000 general Medicaid bulletin article and the November 2000 Special Medicaid Bulletin II regarding the prior approval process for acute psychiatric hospital stays remain the same including the certification of need process.
The N.C. Medicaid program is using an independent contractor to assist us in assuring that psychiatric admissions of patients are appropriate. Below is a summary of the policies and procedures in effect that must be followed for admission approval by all psychiatric hospitals and the general hospitals.
Under federal regulations, the procedures to be followed for the CON vary depending on the status of the patient’s Medicaid at the time of admission. The hospital is responsible for determining the Medicaid status at the time of admission. If the proper procedures for admission approval are not followed, denial of Medicaid payment will be made as indicated below.
I. For patients under the age of 21 who are Medicaid recipients at the time of admission to the hospital:
A. for elective admissions:1. the hospital must:B. for emergency admissions:a. contact ValueOptions at 1-888-510-1150 for admission approval on or before the date of admission. For psychiatric hospitals, federal regulations require that the CON form must be completed on or before the date of admission. Medicaid payment for psychiatric hospitals cannot begin prior to the date the CON is completed. Medicaid payment for the psychiatric units of the general hospitals cannot begin prior to the date ValueOptions’ preadmission approval is completed.2. If ValueOptions determines that they can approve the admission, ValueOptions will:b. supply ValueOptions with the recipient’s MID number. The claims payment system at EDS cannot accept an admission approval until the MID is entered by ValueOptions in the prior approval segment.
a. verbally issue the prior approval and follow this with a written notice of the admission approval. The admission approval is valid for 15 days. Failure to admit the patient within this time frame will necessitate a new admission approval to be initiated by the hospital.3. If ValueOptions is unable to approve the admission, they will notify the patient or patient’s guardian, the hospital, and the patient’s county department of social services (DSS) by certified mail, return receipt requested, with instructions for appeal.b. complete the CON if the admission is to a psychiatric hospital and forward a copy of the CON to the hospital to be maintained in the patient’s medical record for federal or state audit. Approval for Medicaid payment cannot begin prior to the date the CON is completed.
c. send the approval information to EDS.
1. the hospital must:
a. call ValueOptions at 1-888-510-1150 for admission approval within two working days of the admission. Delay in contacting ValueOptions beyond the two days will result in denial of admission approval from the date of admission to the date the hospital contacts ValueOptions to initiate admission approval.b. supply ValueOptions with the recipient’s MID number. The claims payment system at EDS cannot accept an admission approval until the MID is entered by ValueOptions in the prior approval segment.
c. if it is a psychiatric hospital, in addition to other general information needed for admission approval, send ValueOptions the completed state-approved CON form signed by appropriate interdisciplinary team members. A faxed copy of the CON is not acceptable. The hospital should maintain a copy of the completed and signed CON in the patient’s record for federal or state audit.
2. ValueOptions will determine if the admission meets the criteria for emergency admission:"Sudden onset of a psychiatric condition manifesting itself by acute symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in serious dysfunction of any bodily organ/part or death of the individual or harm to another person by the individual."
a. If the admission does not meet the criteria for emergency, ValueOptions must treat the admission as an elective admission (and follow the guidelines listed in I.A. above).3. For psychiatric hospitals, ValueOptions will review the state-approved CON form submitted by the hospital to ensure that the signatures of the interdisciplinary team members are individually dated within 14 days of the admission.b. If the admission meets the criteria for emergency, ValueOptions can continue the admission approval process as outlined below.
a. If both of the signatures are within 14 days of admission, ValueOptions can enter the "start date" for admission approval as the admission date, if:4. If ValueOptions determines that they can approve the admission, ValueOptions will:i) the admission is otherwise approvable, andb. If either of the signatures is beyond the 14 days from admission, the earliest "start date" for admission approval that ValueOptions can enter is the latest date that the CON was signed by either team member, if:ii) the hospital contacted within two working days of admission. If the hospital did not contact within the two working days, ValueOptions will enter the "start date" for admission approval no earlier than the date the hospital contacted ValueOptions to initiate the admission review.
i) the hospital contacted ValueOptions within two working days after admission, (see I.B.3.a.ii above for directions), andc. Admission approval can not be given until ValueOptions has received a valid CON.ii) the admission is otherwise approvable.
Example: date of admission: March 3, 2001
date hospital called XX: March 4, 2001
first CON signature date: March 13, 2001
second CON signature date: March 20, 2001
earliest "start date" for admission approval:
March 20, 2001, if otherwise approvablea. verbally issue approval to the hospital and will follow this with a written notice of the admission approval, and5. If ValueOptions is unable to approve the admission, they will notify the patient or patient’s guardian, the hospital, and the patient’s county DSS by certified mail, return receipt requested, with instructions for appeal.b. submit admission approval information to EDS.
A. the hospital must:1. contact ValueOptions at 1-888-510-1150 for admission approval as soon as the hospital becomes aware of the Medicaid application. The hospital must supply ValueOptions with the applicant’s MID number. (This number is assigned at the time that the application is taken.) ValueOptions cannot complete an admission approval and submit the approval to EDS without the MID.2. if it is a psychiatric hospital, in addition to other required materials for admission approval, send the completed state-approved CON form signed by appropriate interdisciplinary team members. The interdisciplinary team members must certify that the three criteria were met for the date that the hospital is seeking to have Medicaid coverage begin. The hospital should maintain a copy of the completed and signed CON in the patient’s record for federal or state audit.
B. ValueOptions will determine whether admission approval can be given.1. ValueOptions will verify the dates of application and approval for Medicaid eligibility through DMA.
a. If the patient was a Medicaid recipient at the time of admission, ValueOptions must use the appropriate process for admission approval of recipients listed in I.A. or I.B. above.b. If the patient was not a Medicaid recipient at the time of admission, ValueOptions can enter a "start date" for admission approval as early as the date the hospital is seeking to have Medicaid coverage begin, if otherwise approvable.
2. For psychiatric hospital, ValueOptions will review the state-approved CON form submitted by the hospital and will ensure that it is properly completed and signed. The interdisciplinary team members must certify that the three criteria were met for the date that the hospital is seeking to have Medicaid coverage become effective.3. If ValueOptions determines that they can approve the admission, ValueOptions will verbally issue the approval to the hospital and will follow this with a written notice of the admission approval.
a. ValueOptions will send the approval information to EDS.4. If ValueOptions is unable to approve the admission, they will notify the patient or patient’s guardian, the hospital, and the patient’s county DSS by certified mail, return receipt requested, with instructions for appeal.
A. Admission approval by ValueOptions is not a guarantee of Medicaid eligibility. It is a certification of need for admission for inpatient services. The hospital must separately verify the patient’s period of eligibility for Medicaid.B. When submitting the request for admission approval, the hospital must provide ValueOptions with the following information at a minimum. It is vital that the person contacting ValueOptions has all of this information available at the time of the initial contact.
C. When the initial call to ValueOptions does not result in a decision regarding admission approval, if the hospital or physician becomes aware of new or other non-reported information, the hospital or physician should provide the information to ValueOptions at any time up to the date of denial by ValueOptions. Faxed copies can be used; this may avert the need for a peer to peer review.D. Federal regulations do not require that general hospitals have a CON form as defined in 42 CFR 441.152 and 441.153.
E. Admission approval must be secured for all admissions. This includes admissions on the same day as a previous discharge at either the same hospital or a different hospital. (This also includes situations where a patient never left the hospital, but the hospital record shows a discharge and readmission.)
Preadmission Certification Process for Adults
Indications for Hospitalization
The following criteria are to be utilized for preadmission review for
psychiatric treatment of adult (ages 21 through 64) with non-substance
abuse and all other conditions.
Any DSM-IV Axis I or II diagnosis and one of the following:
Note: Concurrent review criteria for adults are listed in NCAC 26I.0113.
Residential Services providers must file an application for enrollment as a Medicaid provider and sign a provider agreement to qualify for reimbursement for Level II, III, IV HRI-Residential Services, and Psychiatric Residential Treatment Facility services. A separate application and provider agreement must be completed for each business site. The enrollment process includes the following steps:
Clinical Case Manager Responsibilities
Federal regulations require a certification of need (CON) form to be completed prior to admission when the recipient is already Medicaid-eligible or Medicaid is pending. The CON must meet all federal requirements and a copy must be maintained in the recipient’s medical record. If application for Medicaid is made after admission, a CON must be done at the time the application is made and the independent utilization reviewer contacted immediately so that review can begin. Authorization for payment will be determined by the latest date of a signature on the CON form.
The following is the minimum data required from the facility representative in order to complete a preadmission certification review:
Concurrent review will occur every 30 days.
PRTFs provide care for children who have a mental illness or substance abuse/dependency and who are in need of services in a nonacute inpatient facility. This service may be provided when an individual does not require acute care but requires supervision and specialized interventions on a 24-hour basis to attain a level of functioning that allows subsequent treatment in a less restrictive setting. This service is available for those under 21 years of age or who are in treatment at age 21. Continued treatment can be provided until the 22nd birthday as long as it is medically necessary. Discharge planning starts on the day of admission.
This is a structured inpatient psychiatric program accredited as a residential treatment facility by the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation. In addition, hospital licensure or 122C licensure is required. This program must be provided under the direction of a board-eligible or certified child psychiatrist or general psychiatrist with demonstrated experience in the treatment of children and adolescents. The services must be therapeutically appropriate and meet medical necessity criteria as established by the state. Documentation requirements must meet both the requirements of the accrediting body and Medicaid guidelines.
A CON process is necessary and must be performed by an independent team that includes a physician who has competence in the diagnosis and treatment of mental illness - preferably in child psychiatry - and has knowledge of the individual’s situation (taken from CFR 441.153). An individual comprehensive service plan must be developed, implemented, and managed on an ongoing basis.
For an individual who applies for Medicaid while in the facility or program, the CON must be performed at the time of application by the team responsible for the plan of care. It must cover any period prior to the application date for which the facility is seeking to have Medicaid coverage begin.
The CON for PRTF services must certify that:
Spectrum of symptoms leading to admission have not remitted sufficiently to allow discharge to a lower level of care or the client has manifested new symptoms or maladaptive behaviors which meet initial authorization criteria and the treatment plan has been revised to incorporate new goals.
AND
Patient shows continued progress towards goals as reflected in documentation and treatment plans must be adjusted to reflect progress.
AND
The patient’s family, legal guardian, or home community is actively engaged in treatment and ongoing discharge planning.
OR
Indicated therapeutic interventions have not yet been employed.
The prior approval process for Levels II, III, and IV residential treatment (in facilities of four beds or more) begins when the area mental health program becomes aware that a recipient is in need of services. An assessment is conducted jointly by the area mental health program and the child and family team to determine medical necessity and the appropriate level of care. Once the level of care is established, the case manager will then contact the independent utilization review contractor for Medicaid. The case manager will provide pertinent recipient information by telephone to the utilization reviewer. At the time of admission, the case manager will give the authorization form to the residential facility to submit to EDS.
The following is the minimum data required from the facility representative in order to complete a preadmission certification review:
Concurrent review by ValueOptions for Levels II and III will begin after the first 120 days.
Concurrent review by ValueOptions for Level IV begins after the first 30 days.
Definition of Service - Level IV
Residential Treatment - Secure
Therapeutic Relationship
This service provides all elements of Residential Treatment - High
plus ability to manage intensive levels of aggressiveness.
Structure of Daily Living
Daily living is structured to provide all elements of Residential Treatment
- High in a physically secure, locked setting including, typically but
not always, locked time-out rooms (used only for the safe management of
out of control behaviors).
Cognitive/Behavioral Skill Acquisition
Treatment provides all Residential Treatment - High elements plus intensive
focus on assisting consumers acquiring disability management skills and
significantly increased onsite interventions from qualified professionals
including psychologists and physicians.
General Characteristics
Additionally, most other service needs are met in the context of Residential
Treatment - Secure setting including school, psychological and psychiatric
consultation, nurse practitioner services, vocational training, recreational
activity, etc. Typically, the treatment needs of consumers at this level
are so extreme that these activities can only be undertaken in a therapeutic
context. These services are conducted in a manner that is fully integrated
into ongoing treatment.
Program Type
Staff is awake during sleep hours and supervision is continuous.
This service includes all Residential Treatment - High elements plus the following activities:
Program Type
Treatment is provided in a structured program setting with staff employed
by, or contracted by, an area program. Staff is present and available at
all times of the day, including overnight awake. A minimum of two direct
care staff are required per six consumers at all times. Additionally,
consultative and treatment services at a qualified professional level shall
be available no less than eight hours per week. Staffing provisions
apply as with Residential Treatment - High.
In addition to meeting Residential Treatment - High medical necessity criteria, the following must be satisfied:
1. Consumer is medically stable, but may need significant intervention to comply with medical treatment.2. Meets Level D criteria/NCSNAP (developmental disabilities assessment tool).
Consumer’s needs cannot be met with Residential Treatment - High services.
The consumer is experiencing any one of the following:In addition to meeting Residential Treatment - High medical necessity criteria, the following must be satisfied:
- Frequent and severe aggression including verbal aggression and property damage or harm to self or others and unmet needs for safety, containment of aggressive or dangerous behaviors.
- Severe functional problems as defined in Residential Treatment - High coupled with demonstrated inability to maintain treatment in an unlocked setting as evidenced by, but not limited to, history of eloping from unlocked facilities, or inability to become stabilized in anything but a locked facility.
- Medication administration and monitoring has alleviated limited or no symptoms and other treatment interventions are needed to control severe symptoms or to ensure safety.
May be related to the presence of severe affective, cognitive, or behavioral problems or developmental delays or disabilities.
- Consumer is medically stable but may need significant intervention to comply with medical treatment.
A sex offender specific evaluation (SOSE) shall be provided by a trained professional in conducting the SOSE, and a level of risk shall be established (low, moderate, high) through the use of at least three risk assessment tools.- Meets Level D criteria/NCSNAP.
Consumer’s needs cannot be met with Residential Treatment - High services.
The consumer is experiencing any one of the following:Service Order Requirement
- Frequent and severe aggression including verbal aggression and property damage or harm to self or others and unmet needs for safety, containment of aggressive or dangerous behaviors.
Risk of offending or predatory sexual behavior is high with inadequate supervision that puts the community at high risk for victimization.- Severe functional problems as defined in Residential Treatment - High coupled with demonstrated inability to maintain treatment in an unlocked setting as evidenced by, but not limited to, history of eloping from unlocked facilities, or inability to become stabilized in anything but a locked facility.
- Medication administration and monitoring has alleviated limited or no symptoms and other treatment interventions are needed to control severe symptoms or to ensure safety.
May be related to the presence of severe affective, cognitive, or behavioral problems or developmental delays or disabilities.
High risk for sexual reoffense.- Experiences severe limitations in ability to independently access or participate in other human services and requires intensive, active support, supervision and onsite access to all routinely needed services.
- Has severe deficits in ability to manage personal health, welfare, and safety without intense support and supervision.
To include sexual behaviors.- Severe aggressive and dangerous episodes may be without provocation or predictable, identifiable triggers.
Has deficits that put the community at risk for victimization unless specifically treated for sexual aggression problems.
Continuation
Consumer continues to have the need and continues to benefit as outlined
in their service plan.
Utilization review must be conducted at a minimal of every 30 days and so documented in the service record.
Discharge Criteria
The consumer shall be discharged from this level of care if any one
of the following is true:
The level of functioning has improved with respect to the goals outlined in the service plan and can reasonably be expected to maintain these gains at a lower level of treatment.
The consumer no longer benefits from service as evidenced by absence of progress toward service plan goals and more appropriate service(s) is available.Any denial, reduction, suspension or termination of services requires notification to the consumer about their appeal rights.
Discharge or step-down services can by considered when in a less restrictive environment the safety of the consumer around sexual behavior and the safety of the community can reasonably be assured.
Service Maintenance Criteria
If consumer is functioning effectively at this level of treatment and
discharge would otherwise be indicated, this level of service should be
maintained when it can be reasonably anticipated that regression is likely
to occur if the service were to be withdrawn. This decision should be based
on at least one of the following:
Provider Requirements - Program Type (Family type is not applicable)
The minimal requirements are a high school diploma or GED, associate
degree with one year of experience or a four-year degree in the human service
field or a combination of experience, skills, and competencies that is
equivalent. Skills and competencies of this service provider must be at
a level that include structured interventions in a contained setting to
assist consumer in acquiring control over acute behaviors.
In addition to the above, special training of the caregiver is required in all aspects of sex offender specific treatment.
Implementation of therapeutic gains is the goal of the placement setting.
Must meet requirements established by state personnel system or equivalent for job classifications. Weekly supervision is provided by a qualified professional for 60 minutes.Documentation RequirementsSupervision provided by a qualified professional with sex offender specific expertise, is onsite per shift.
Documentation includes the specific goals of sex offender treatment as supported and carried out through the therapeutic milieu and interventions outlined in the service plan.
Definitions of Service - Level III
Residential Treatment - High
Therapeutic Relationship
This service provides all Family/Program Residential Treatment elements
plus relationship which is structured to remain therapeutically positive
in response to grossly inappropriate and provocative interpersonal consumer
behaviors including verbal and some physical aggression.
Structure of Daily Living
Daily living is structured to provide all elements of Family/Program
Residential Treatment plus intensified structure, supervision, and containment
of frequent and highly inappropriate behavior. This setting is typically
defined as being "staff secure."
Cognitive/Behavioral Skill Acquisition
Treatment provides all Family/Program Residential Treatment elements
plus active "unlearning" of grossly inappropriate behaviors with intensive
skill acquisition. Includes specialized, onsite interventions from qualified
professionals.
General Characteristics
Residential Treatment - High service is responsive to the need for
intensive, active therapeutic intervention, which requires a staff secure
treatment setting in order to be successfully implemented. This setting
has a higher level of consultative and direct service from psychologists,
psychiatrists, medical professionals, etc.
Program Type
Staff is awake during sleep hours and supervision is continuous.
This service includes all Family/Program Residential Treatment elements and the following activities:
Program Type
Treatment is provided in a structured program setting with staff employed
by, or contracted by, an area program. Staff is present and available at
all times of the day, including overnight awake. A minimum of one staff
is required per four consumers at all times. Additionally, consultative
and treatment services at a qualified professional level shall be available
no less than four hours per week. This staff time may be contributed
by a variety of individuals. For example, a social worker may conduct group
treatment or activity; a psychologist may consult on behavioral management;
or, a psychiatrist may provide evaluation and treatment services. These
services must be provided at the facility site. Group therapy or activity
time may be included as total time per consumer (i.e., if there are six
members in a group for 90 minutes, this may be counted as 90 minutes per
consumer).
In addition to meeting Family/Program Residential Treatment medical necessity criteria, the following must be satisfied:
1. Consumer is medically stable but may need significant intervention to comply with medical treatment.2. Meets Levels D criteria/NCSNAP.
In addition to meeting Family/Program Residential Treatment medical necessity criteria, the following must be satisfied:
- Consumer is medically stable but may need significant intervention to comply with medical treatment.
A sex offender specific evaluation (SOSE) shall be provided by a trained professional in conducting the SOSE, and a level of risk shall be established (low, moderate, high) through the use of at least three risk assessment tools- Meets Level D criteria/NCSNAP.
A sex offender specific evaluation (SOSE) shall be provided by a trained professional in conducting the SOSE, and a level of risk shall be established (low, moderate, high) through the use of at least three risk assessment tools
Continuation/Utilization Review
The consumer continues to have the need or can benefit from this level
of care as documented in their service plan.
Utilization review must be conducted at a minimal of every 30 days and so documented in the service record.
Discharge Criteria
The consumer shall be discharged from this level of care if any one
of the following is true:
The level of functioning has improved with respect to the goals outlined in the service plan and can reasonably be expected to maintain these gains at a lower level of treatment.
The consumer no longer benefits from service as evidenced by absence of progress toward service plan goals and more appropriate service(s) is available.Any denial, reduction, suspension or termination of services requires notification to the consumer about their appeal rights.
Discharge or step-down services can be considered when in a less restrictive environment the safety of the consumer around sexual behavior and the safety of the community can reasonably be assured.
Service Maintenance Criteria
If consumer is functioning effectively at this level of treatment and
discharge would otherwise be indicated, this level of service should be
maintained when it can be reasonably anticipated that regression is likely
to occur if the service were to be withdrawn. This decision should be based
on at least one of the following:
Provider Requirements - Program Type (Family Type is not applicable)
The minimal requirements are a high school diploma or GED, associate
degree with one year of experience or a four-year degree in the human service,
or a combination of experience, skills, and competencies that is equivalent.
Skills and competencies of this service provider must be at a level that
offers psychoeducational, relational support, and behavioral modeling interventions
and supervision. These preplanned, therapeutically structured interventions
occur as required and outlined in the consumer’s service plan.
In addition to the above, special training of the caregiver is required in all aspects of sex offender specific treatment.
Implementation of therapeutic gains is the goal of the placement setting.
Must meet requirements established by state personnel system or equivalent for job classifications. Weekly supervision is provided by a qualified professional for 60 minutes.Documentation RequirementsSupervision provided by a qualified professional with sex offender-specific treatment expertise is available per shift.
Documentation includes the specific goals of sex offender treatment as supported and carried out through the therapeutic milieu and interventions outlined in the service plan.
Definitions of Service - Level II
Family/Program Type Residential Treatment
Therapeutic Relationship
This treatment provides all Family/Program Type Residential Treatment
elements plus provision of a more intensive corrective relationship in
which therapeutic interactions are dominant. Focus is broadened to include
assisting consumer in improving relationships at school or work and other
community settings.
Structure of Daily Living
Daily living is structured to provide all elements of Family/Program
Type Residential Treatment with a higher level of structure and supervision.
Cognitive/Behavioral Skill Acquisition
Treatment provides all Family/Program Type Residential Treatment elements
with a complete emphasis on individualized interventions for specific skill
acquisition that enable the consumer to achieve or maintain the highest
level of independent functioning.
General Characteristics
This level of service is responsive to the need for intensive, interactive,
therapeutic interventions, which still fall below the level of staff secure/24-hour
supervision or secure treatment settings. The staffing structure may include
family and program type settings.
Program Type
The staff is not necessarily awake during sleep time, but must be constantly
available to respond to consumer needs, while consumers are involved in
educational, vocational, and social activities or other activities except
for periods of planned respite.
Family Type
The provider is not necessarily awake during sleep time but must be
constantly available to respond to consumer needs, while consumers are
involved in educational, vocational and social activities or other activities
except for periods of planned respite. This service in the family or program
settings includes Family Type Residential Treatment elements and the following
activities:
Family Type
This treatment may be provided in a natural family setting with one
or two surrogate family members providing services to one or two consumers
per home.
Program Type
Treatment is provided in a structured program setting with staff employed
by, or contracted by, an area program. Staff is present and available at
all times of the day. A minimum of one staff is required per four consumers
at all times.
In addition to meeting Family Type Residential Treatment medical necessity criteria, the following must be satisfied:
1. The consumer is medically stable, but may need some intervention to comply with medical treatment.2. Meets Level C criteria/NCSNAP.
The consumer’s needs cannot be met with Family Type Residential Treatment services.
The consumer is experiencing any one of the following:
The consumer’s needs cannot be met with Family Type Residential Treatment services.
The consumer is experiencing any one of the following:
Continuation/Utilization Service Review
The consumer continues to have the need and continues to benefit as
outlined in their service plan.
Utilization review must be conducted at a minimal of every 30 days and so documented in the service record.
Discharge Criteria/Review
The consumer shall be discharged from this level of care if any one
of the following is true:
The level of functioning has improved with respect to the goals outlined in the service plan and can reasonably be expected to maintain these gains at a lower level of treatment.
The consumer no longer benefits from service as evidenced by absence of progress toward service plan goals and more appropriate service(s) is available.Any denial, reduction, suspension or termination of services requires notification to the consumer about their appeal rights.
Discharge or step-down services can be considered when in a less restrictive environment, the safety of the consumer around sexual behavior, and the safety of the community can reasonably be assured.
Service Maintenance Criteria
If the consumer is functioning effectively at this level of treatment
and discharge would otherwise be indicated, this level of service should
be maintained when it can be reasonably anticipated that regression is
likely to occur if the service were to be withdrawn.
This decision should be based on at least one of the following:
Provider Requirements - Family Type
The minimal requirements are a high school diploma or GED with experience
in the human service field.
Provider Requirements - Program Type
The minimal requirements are a high school diploma or GED or associate
degree with one year of experience or four-year degree in the human service
field. Skills and competencies of this service provider must be at a level
that offers psychoeducational, relational support, and behavioral modeling
interventions and supervision. These preplanned, therapeutically structured
interventions occur as required and outlined in the consumer’s service
plan
In addition to the above, special training of the caregiver is required in all aspects of sex offender specific treatment.
Implementation of therapeutic gains are to be the goal of the placement setting.
Must meet requirements established by state personnel system or equivalent for job classifications. Weekly supervision is provided by a qualified professional for 60 minutes.Documentation RequirementSupervision provided by a qualified professional with sex offender-specific treatment expertise, is available for a total of at lease 60 minutes. On-call and back-up plan with a qualified professional is also available.
Levels II through IV should be billed on the UB-92 claim form as well. For Level II, the RCC 902 is entered in form locator 42. A corresponding Y2346 is entered in form locator 44. It is to be billed as one unit per day for a span of days.
For Level III, the RCC 902 is entered in form locator 42. A corresponding Y2345 is entered in form locator 44. It is to be billed as one unit per day for a span of days.
For Level IV, the RCC 902 is entered in form locator 42. A corresponding
Y2344 is entered in form locator 44. It is to be billed as one unit per
day for a span of days.
| 42
Rev Code |
43
Description |
44 HCPCS/Rates | 45
Serv Date |
46
Serv Units |
47
Total Charges |
48
Noncovered Charges |
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), also referred to as the Kennedy-Kassesbaum Act, is a federal law, which was signed by President Clinton on August 21, 1996. The purpose of the Act is to protect health insurance coverage for workers and their families when they change or lose their jobs. In order for transitional insurance coverage to be provided, administrative reforms were instituted. Standardization of billing across the nation is one such reform, which is now mandated. The mandate for standardized billing necessitates uniform health care identifiers and requires codes to be recognizable, and consistent.
Current Procedure Terminology (CPT) is a listing of descriptive medical, surgical, and diagnostic services, which are assigned an identifying five-digit code. The purpose of the CPT codes is to simplify the reporting of services through standardization. Previous billing codes should be converted to the corresponding CPT codes.
The transition from state-created codes to CPT codes or some other national code must be completed by August, 2002. The first stage of this transition for mental health Y codes is as follows:
The Mental Health codes Y2305 (outpatient individual) and Y2306 (outpatient group) are to be broken out and billed separately. The services provided under the old Y2305 and Y2306 are as follows:
The following CPT codes are physician codes only: 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829, 90862, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215.
Licensed OT, PT, and speech therapists can now bill OT, PT, and speech therapy separately. This was previously a part of outpatient therapy, and was coded Y2305 and Y2306.
Psychological and developmental testing should be billed by psychologists using CPT codes 96100 through 96117.
There is also evaluations in management codes available, these CPT codes are 99202 through 99215. These codes can be used, if this better describe the service rendered, and specified documentation requirements are met. The required documentation consists of a history, physical and medical decision process.
All other area program staff, not mentioned above should continue to bill Y2305 and Y2306 when providing any outpatient service as they currently do. These outpatient services consist of the following:
Removal of Limits to CPT Code 90862
Effective with dates of service May 1, 2001, edits have been removed that limit the billing of CPT code 90862 (pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy) to once every 30 days. Beginning May 1, 2001, this code will not have any limitations nor will it be subject to prior approval. It will not count in the 26 unmanaged visits for the under 21 population but does count in the 24 annual visits for adults.
Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
| ______________________ | _______________________ | ||
| Nina M. Yeager, Director | Ricky Pope | ||
| Division of Medical Assitance | Executive Director | ||
| Department of Health and Human Services | EDS | ||
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