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Ambulatory Patient Groups (APG) Policy and Medicaid Billing Guidance OASAS Certified Outpatient Chemical Dependence Programs - PDF
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1 Ambulatory Patient Groups (APG) Policy and Medicaid Billing Guidance OASAS Certified Outpatient Chemical Dependence Programs
2 TABLE OF CONTENTS SECTION: PAGE 1. Background and Introduction 3 2. Manual Purpose 3 3. Forward: APG clinical Guidance Overview and APG Section APG Service Categories and Guidance 9-39 Screening/Brief Intervention/Brief Treatment 9-13 Medication Supported Recovery 14 Medication Administration and Observation Medication Management Routine 16 Medication Management Complex 17 Addiction Medication Induction Assessment: Brief; Normative; or Extended Individual Counseling Brief or Normative Group Counseling Collateral Visit Complex Care Coordination Peer Support services Intensive Outpatient Service Outpatient Day Rehabilitation Physical Health Services APG Medicaid Billing History Transition from the Rate Based Single Medicaid Claim Submission under APGs Laboratory Services Pharmaceuticals Billing Code and Billing Rule Summary Tables Billing/Clinical Scenarios General Medicaid Billing APG Pricing The On-line Provider Revenue Calculator Sample Encounter Form 58 Guidance June
3 Section One: Background and Introduction to Ambulatory Patient Groups in OASAS Certified Outpatient Programs Implementing Ambulatory Patient Groups (APGs) for behavioral health services has been a key component of New York State s overall effort to reform Medicaid reimbursement and rationalize service delivery. Clinically, for the addiction field, the implementation of APGs is an integral part of the evolutionary move by the addictions field towards one outpatient system of care. APGs support a range of medically necessary clinic services for patients based on the evidence of what works to promote recovery from chemical dependency. From a Medicaid reimbursement perspective, the new APG reimbursement methodology replaced the threshold visit reimbursement system for OASAS certified clinic and rehabilitation programs, opiate treatment, and outpatient chemical dependency for youth programs. The APG payment methodology pays differential amounts for ambulatory care services based on the resources required for each service provided during a patient visit. In addition, APGs will: support discrete Medicaid reimbursement for some chemical dependence services that were not previously billable; and, allow for some services that are integral to the treatment of patients in chemical dependency treatment such as mental and physical health services. Section Two: Manual Purpose The purpose of this manual is to provide: Clinical Guidance: Support OASAS certified outpatient programs understanding of the new APG service categories; their clinical intent; and, any restrictions on what level of practitioner may deliver a particular service. On Line Frequently Asked Questions: Programs are also advised to view the on-line APG FAQS at: Medicaid Policy and Billing Guidance: Support OASAS certified outpatient programs understanding of how to bill Medicaid under the APG payment methodology. Of immediate note is that under APGs, programs must use certain APG specific CPT and HCPCS codes to bill Medicaid and, programs will, for the same patient on the same visit date, be able to bill Medicaid for multiple services. APG specific category and general APG Medicaid rules will be discussed throughout the manual. The service definitions and associated CPT or HCPCS codes listed in this manual are for the purposes of billing the New York State Medicaid program. It is recognized that in some instances the OASAS service definition and applicable CPT or HCPCS codes may vary from: the service definition listed in the CPT or HCPCS manuals; and/or, be different from how the codes are used for commercial or Medicare billing. Programs should use the codes as listed in this manual for billing the New York State Medicaid program, and use Medicare or commercial coding as indicated by the relevant billing / coding guidelines. Guidance June
4 Section Three: Forward OASAS Regulation - Part 822 provides the regulatory structure necessary for outpatient clinic (formerly Part 822) and (formerly Part 828) outpatient opiate treatment programs to implement both the program and billing aspects of Ambulatory Patient Groups (APGs). This guidance manual document provides more specific guidance on the clinical issues and Medicaid billing parameters for each APG and overall program implementation. It is the responsibility of each OASAS certified Part 822 program to ensure the appropriate clinical, documentation and billing parameters have been met and that billing claims meet all regulatory requirements. This document is meant to support programs in meeting this responsibility. APG Service Categories: OASAS worked with the Department of Health, the Office of Mental Health, the Office of Persons with Developmental Disabilities, and providers to create APG billing categories that accurately reflect the scope of clinic services. APGs provide uniformity in Medicaid billing for behavioral health entities across disabilities and were also created to maintain service delivery patterns unique to each disability. The document will identify shared APG categories and categories unique to OASAS. Specifically, under APGs the outpatient chemical dependence service array was disaggregated from the former large categories of: assessment, individual and group services and the previous methadone week into discrete clinically related service delivery and billing categories. The new categories capture the major behavioral health service groupings that are delivered in OASAS certified: Outpatient/Outpatient Rehabilitation Chemical Dependence Clinic programs; Opioid Treatment Programs (OTP) and the former Part 823 Outpatient Chemical Dependence for Youth Clinics and includes: SERVICE CATEGORIES Screening, Brief Intervention and Brief Treatment Medication Administration and Observation Medication Management Routine Medication Management Complex Addiction Medication Induction Assessment Brief Assessment Normative Assessment Extended Intensive Outpatient Services (IOS) Individual Counseling Brief Individual Counseling Normative Group Family/Collateral Visit Complex Care Coordination Peer Support Outpatient Rehabilitation NOTE: Detailed Rules regarding APG Medicaid billing and associated OASAS rules are discussed throughout this manual. However, of immediate OASAS regulation, Medicaid APG billing is generally limited to no more than two services per visit date. For example, a program may bill and receive an individual service on the same visit date, but may not bill for two group services on the same visit date. 4
5 APG Service Parameters: Diagnosis: Admitted patients must have a diagnosis of substance use disorder. Due to the current social work exemption law, clinical staff in a program are able to gather information that will enable a qualified health professional to formally establish a substance use disorder diagnosis. Each patient should be presented and have the comprehensive treatment / recovery plan reviewed at the multidisciplinary team conference. Clinical Staff: Staff who provide services directly to patients, including licensed staff, credentialed staff, noncredentialed staff, and student interns. Clinical staff includes medical staff. Medical Staff: Physicians, nurse practitioners, registered physician s assistants, registered nurses, and licensed practical nurses licensed and/or certified by the State Education Department practicing within the scope of, and in accordance with, the terms and conditions of such licenses and certifications, and working with, or under the supervision of, a physician, if required by law. Prescribing Professional: Is any medical professional appropriately licensed under New York State law and registered under federal law to prescribe approved medications. Visit: Means one or more services provided to a patient and/or collateral person on a single given day. Episode of Care: For a Part Outpatient Clinic, an episode is the period of time between beginning with first faceto-face service that leads to admission (to a chemical dependence outpatient treatment program) within 60 days and concluding 30 days following the discharge date. For a Part Opiate Treatment Program, an episode is the period beginning with admission of a patient to the program and concluding every 12 months thereafter. This 12- month Opiate treatment episode refers to the period of care and should not be confused with the OTP Medicaid weekly billing episode discussed in APG Medicaid claims submission section of this manual. The episode of care applies to the treatment of the patient by the program and will not extend to previous or concurrent treatment at another program whether that treatment is known or unknown. Documentation: Each service category will have unique documentation requirements but all must meet documentation of services requirements. e.g. date of service; service duration, and signed by the staff member providing the service. The requirements will not be repeated in each service category. Clinical Justification: In some APG categories (Outreach, IOS, Collateral Services), a clinical justification is required beyond a set service number. For example, in the case of IOS, the clinical staff must document the need for continuation in that level of care after six weeks of service. When clinical justification is required, the clinical staff person must document, in a progress note or treatment / recovery plan, the clinical reasons for the need for continued services in this category and identify the projected number of additional services. Clinical justification must include the following elements: date, number of additional services projected, clinical reasons for the need for these services including a rationale for the level of care, and the signature of clinical staff person if IOS. 5
6 Co-occurring Disorder Treatment OASAS and OMH convened a task force in 2008 to recommend action to improve access to integrated treatment for substance use and mental health disorders. A summary of the recommendations of the task force, the Memorandum of Understanding signed by the Commissioners and supporting documentation can be found at this link: The implementation of APGs will support the treatment of patients with co-occurring disorders, but will not change the billing for co-occurring disorder treatment in OASAS certified settings. The OASAS service category map includes services that will support treatment, medication evaluation and ongoing monitoring and other clinical services including group, individual and family treatment for meeting the patient s treatment / recovery plan. The comprehensive evaluation and treatment / recovery plan should include an assessment of mental health problems and plan for intervening. Providing that the staff are working within their scope of practice as defined by the State Education Department and have the experience necessary to provide treatment for co-occurring mental health disorders, they may be provided directly and billed for in an OASAS certified outpatient clinic. In most circumstances, the OASAS service categories and HCPCS or CPT codes provided in this manual should be used for providing services for co-occurring treatment. When a program provides psychiatric evaluation, the program may use the E/M codes for Physical Exam or history problem focused if the evaluation is provided without counseling. Effective December 31, 2012 codes and were eliminated by the American Medical Association. Therefore, going forward effective January 1, 2013 it is necessary to billing psychiatric evaluation with counseling using E&M codes shown below (selected based on complexity) and an add-on code of or CPT add-on code is used to bill for psychiatric evaluation with counseling- brief and CPT add-on code is used to bill for psychiatric evaluation normative. CONTINUED ON NEXT PAGE 6
7 Physical History and Exam Problem Focused Psychiatric Consultation New/Established Patient Select CPT Code From Range: NEW PATIENT ESTABLISHED PATIENT Smoking Cessation Smoking cessation can be billed in a chemical dependency clinic by a clinical (including medical) staff person. Staff that provides this service needs to have specific tobacco cessation training. Documentation of the training should be kept in the clinical staff s personnel file. No more than three smoking cessation services should be billed in an episode of care. Additionally, smoking cessation is not a third visit exempt billable service. Smoking cessation will be billed under the APG clinic rate code, not the health services rate code and will, therefore, not apply to the 5% medical visits rule. Clinical Guidance Smoking cessation must be provided by trained staff and includes both counseling and access to medication including nicotine replacement therapies (NRTs); this would include any clinical staff with the appropriate training. OASAS has additional guidance on providing tobacco cessation including a link to free on-line training on the website at: Smoking Cessation is a specific face-to-face intervention provided to an individual. This code may not be billed for specific smoking cessation interventions provided in a group. The inclusion of these codes in no way limits programs from addressing nicotine use disorder as a part of the overall chemical dependency treatment provided in either group or individual sessions according to the treatment / recovery plan. For example, a program may provide a group related to relapse prevention and in the course of that group cover a variety of issues related to relapse including continued tobacco use. The program would then bill for a routine group session. If the patient meets with a nurse, who counseled the patient individually on strategies to quit tobacco use and provided information on over-the-counter nicotine replacement therapy, the program would bill for this additional service using the smoking cessation codes below. Use the following HCPCS codes for smoking cessation treatment: Behavior Change Smoking 3-10 min 451 SMOKING CESSATION TREATMENT Smoking > 10 min 451 SMOKING CESSATION TREATMENT 7
8 Nursing Staff Nurses in OASAS clinics qualify as both medical and clinical staff. They are qualified to provide all clinical services and may qualify to bill E/M codes within the scope of their practice and as allowable within normal billing and coding practice within the scope of health services delineated in this manual. Nurses may bill for nursing assessments by billing an assessment visit prior to patient admission or an individual counseling code after treatment as the purpose of the visit is to develop the treatment / recovery plan. To the extent that patients are provided counseling by nursing staff to meet the goals of the treatment/ recovery plan, these counseling sessions can be billed according to the plan. Nurses may provide smoking cessation treatment and chronic condition education and management. These will generally be provided as a counseling service, per treatment / recovery plan. APG Category Layout Each APG category section will incorporate: service time duration; staff requirements; service definitions; clinical guidelines; category specific HCPCS / CPT billing codes; and APG category specific Medicaid billing requirements. Additionally, at the end of the overall APG Category Section there is a general APG Medicaid billing section, including a section with guidance on when a physician fee schedule claim may be submitted in addition to the APG service claim. 8
9 Section Four: APG Service Categories and Guidance APG Service Category: Screening / Brief Intervention Time Requirements Time: 15 minute minimum NOTE: Both the screening and brief intervention services and codes (H0049 and H0050) are for the purposes of chemical dependence services only and may not be used for Mental Health screens. Delivering Staff Staff: Clinical and/or medical staff as defined in Part 822 (working within their scope of practice). Effective March 31, 2013, licensed providers reimbursed by Medicaid must complete an OASAS 4 hour approved training to continue to bill Medicaid for SBIRT services beyond March 31, Health educators and unlicensed practitioners must complete at least 12-hours of training facilitated by an OASAS approved SBIRT training provider prior to offering SBIRT services. To learn more about SBIRT training requirements visit: Service Definitions Screening is a face-to-face meeting (e.g. not a phone interview) with a clinical staff member for the purpose of identifying alcohol or other drug (substance) use problems through the use of one of the following screening tools: AUDIT, CAGE, CAGEAID, CRAFFT, Simple Screen, GAIN Quick, ASSIST, DAST, RIASI; MAST or other OASAS approved screening tool. The screening tool can be completed through a computer or written format or conducted as a part of an interview. The results must be shared by the clinical staff in an individual face to face session. The focus of the screening session is on the results of the screening and feedback about the likelihood of a substance misuse problem. Screening is not intended to be provided to all patients or where it is known that the patient is appropriate for admission (e.g. a court order); has an assessment from another program; or presents with circumstances that indicate that a substance use disorder (SUD) problem may be present. Additionally, screening may not be provided in a group setting. APG CPT / HCPCS Screening Billing Code H minute minimum Category Specific Medicaid Billing Limitations: Service is an on-site, pre-admission service. No more than one screening per patient per episode of care. 9
10 Clinical Guidance - Screening This service category allows programs to bill for SBIRT activities. The definition includes both screening and brief interventions that may be delivered separately or together. Each service must meet all requirements identified in the definition to qualify as a reimbursable service. Programs that provide screening must utilize a validated screening tool to determine likelihood of a substance use disorder. Screening tool must have evidence supporting validity and reliability. Acceptable screening tools include but are not limited to: ASSIST SIMPLE SCREEN CAGE RIASI AUDIT MAST CRAFFT CAGEAID GAIN QUICK DAST The screening tool can be completed through a computer, written format, or conducted as a part of an interview. The results must be shared with the patient by the clinical staff in an individual face- to- face session. The focus of the screening session is on the results of the screening and feedback about the likelihood of a substance misuse problem. The clinical staff should use a motivational approach to collaborate with the patient, offer options and elicit the patient s own concerns. The clinical staff person may offer a referral to treatment, if further assessment is indicated by the screening results, or offer a brief intervention to reduce risky use. Screening may be a distinct service or offered in conjunction with a brief intervention. Programs may use this category to bill for screenings for patients referred following a DWI conviction to meet the legal requirement for a screening. OASAS has issued standards for completing DWI screening procedures at the following link: Programs may bill the screening as a screening visit or a brief assessment, whichever is most appropriate to the services actually delivered. An example of the elements of a documented Screening session follows: 15 minute session 8:30 am 8:45 am Patient A completed the AUDIT screening tool and met with clinical staff to discuss results. Clinical staff provided feedback on the patient s score of 10 which indicates that the patient is at risk of having a substance use problem. Reviewed positive responses and offered feedback on how this drinking pattern may have a negative impact on health, behavior or safety. Elicited patient s reaction and own concerns/ambivalence about drinking pattern and identified negative consequences. Patient was referred for an assessment appointment. Brief Intervention is a face-to-face pre-admission meeting with the clinical staff when screening results indicate at risk behavior, individuals receive brief interventions. The intervention educates them about their substance use, alerts them to possible consequences, and motivates them to change their behavior. A brief intervention may follow a screening where some risky use has been identified but the patient does not need or accept a referral to treatment. Brief Intervention may not be billed using this code if it is provided in a group setting. 10
11 APG CPT/HCPCS Brief Intervention Billing Code H minute minimum Category Specific Medicaid Billing Limitations The program may bill up to three Brief Intervention visits prior to admission. Screening and Brief Intervention are not considered assessment visits and will not count against the assessment billing limits. Clinical Guidance - Brief Intervention This service category is a pre-admission service for the purpose of educating patients with a risky substance use pattern to reduce use and to motivate those who have a need for a referral to treatment to accept a referral does not require a level of care determination. A brief intervention may follow a screening session or a program may accept referrals from a primary care provider when the person has screened positive for a brief intervention or treatment. This category may also be used for individuals who have been screened for the Drinking Driver program and have a pattern of risky use, but do not meet the program s admission criteria, where this is clinically indicated by the risk scores obtained in a validated screening tool, and/or other evidence of high risk substance use that does not meet the DSM 5 criteria for substance use disorder. Programs may bill for up to three brief intervention sessions prior to admission. Following the pre-admission brief intervention services, the program must, where appropriate offer a referral to the individual for treatment or link to a primary care provider, e.g. Private practitioner, Federally Qualified Health Center or Public Health Clinic. Brief Intervention does not apply to the limitation that programs may bill up to three assessments visits prior to admission. An example of the elements of a documented Brief Intervention session follows: 15 minute session 1:15pm - 1:30 pm Patient A scored positive for risky alcohol use on the ASSIST screening tool. Session focused on providing feedback about low/no-risk drinking patterns. Clinical staff worked with patient to identify specific examples of risky use over past month and strategies for drinking within low-risk limits. Patient will keep a log of drinking and bring to next session. 11
12 APG Service Category: Brief Treatment Time Requirements Time: 15-minute minimum. Delivering Staff: Clinical and/or medical staff as defined in Part 822 (working within their scope of practice) Service Definition Brief Treatment is a post admission face-to-face meeting with a clinical staff and active patient in chemical dependency treatment must include a target behavior (for example, continued use of cocaine, attendance at group sessions, or identification of recovery supports) and identify the evidence-based or clinical practice that the intervention is based upon. Evidence-based practices have empirical evidence to support their efficacy and effectiveness with substance use disorder populations. Brief treatments can be used throughout the course of longer periods of treatment to meet specific goals, motivate patients, address emergent issues related to successful treatment; or support pharmacotherapy. Clinical Guidance - Brief Treatment This service category is a post-admission service. Individuals that meet the program s admission criteria and who present with impairment from substance use and may benefit from a period of brief treatment targeted at reducing or eliminating substance use. Patients may be referred from primary care settings, drinking driver programs or other referral sources. They typically function well in most areas, and are able to make changes in substance use patterns with minimal support. The targeted substance use and evidenced based treatment must be delivered according to the treatment / recovery plan or must address emergent issues related to successful treatment. Brief treatment may also be used in the course of ongoing substance use disorder treatment. The clinical staff must identify a target behavior for example, use of a secondary substance; attendance at group; or developing a connection to recovery supports. The clinical staff member must also identify the evidence- based practice that was used, for example, BRENDA; FRAMES; Motivational Interviewing; or Contingency Management. Some brief treatment approaches such as BRENDA (Volpicelli, J. Pettinati, H. 2001) and Medical Management (Pettinati et al 2004) have been developed to support pharmacotherapy. The focus of these brief treatments include: medication compliance; reduction or elimination of substance use disorder criteria; participation in recovery supports or treatment; emergent issues and increased healthy behaviors to support recovery. An example of a documented Brief Treatment session follows: 15-minute session 9:00 am-9:15 am Patient A continues to take methadone as prescribed and has no cravings, urges or use of opiates. The patient has continued to abuse cocaine sporadically. This session focused on cocaine use. Clinical staff utilized motivational interviewing to identify patient s ambivalence about discontinuing cocaine use and identified with the patient how the continued use interferes with the goal of reducing take-home medications. Clinical staff will continue to work with client to identify internal reasons to stop using cocaine. Category Specific Medicaid Billing Limitations One Brief Treatment service Per Day. Service is a post admission, on-site service. A brief treatment may be billed on the same day as other categories, including, but not limited to individual or group counseling services. 12
13 APG CPT / HCPCS Billing Code for Post-Admission Brief Treatment For all dates of service up to 3/31/13 Part Clinic Brief Treatment Part Opioid Brief Treatment H0050 H0050 For dates of service 4/1/13 forward Part Clinic Brief Treatment Part Opioid Brief Treatment H0004 H
14 APG Service Category: Medication Administration and Observation Time Requirements Time - No time minimum Delivering Staff Medical staff as defined in Part 822 (working within their scope of practice). Note: under the consolidated regulations, Part 822 regulations apply to Outpatient Clinic (822-4) and Opiate Outpatient Programs (Part 822-5) (Formally Part 828). This and all other APG services are appropriate for delivery in either an outpatient clinic or an opiate treatment program. Service Definitions Administration or dispensing of a medicine via oral or non-oral route by a medical staff person appropriate to scope of practice, to be delivered in conjunction with observation of the patient prior to the administration and after as appropriate to the medication and patient condition. Face-to-face Administration is the act of giving the patient the medication a liquid to be swallowed, a pill to be swallowed, a solution to be injected for immediate use. Dispensing is the act of giving the medication to the patient for use at a later date outside the clinic setting a pharmacy dispenses. Clinical Guidance The administration or dispensing of a medication involves the actual delivery of a medicine to the patients. Examples include the dispensing of methadone or the injection of Vivitrol by medical staff person. There must be an order from a prescribing professional who meets state and federal requirements for the medications dispensed to a patient. Medical staff should determine any contraindications for the administration and observe patients following administration as clinically indicated by the patient history, novelty of the medication, dosage changes and medical conditions that may affect the way a patient responds to the medication. Self-administration of a medication does not qualify for reimbursement under this APG category. For example, patients may bring suboxone from their own prescription to the clinic for an induction visit; this is a self-administration of a medication and does not qualify for a medication administration visit. (It does qualify as a medication management visit). Documentation: A note signed by a medical staff person recording what medications were administered and/or dispensed. The note should reflect any symptoms, side effects or other medical concerns noted in the observation, actions taken and plan. The electronic log-in of the appropriate medical staff and record of dose delivered will meet the documentation requirement of a signed note for Medication Administration when there are no observed symptoms, sideeffects or medical concerns noted. CONTINUED ON NEXT PAGE 14
15 APG CPT /HCPCS Billing Code H0020 Methadone Administration- methadone administration only Effective 1/7/2013 programs must add the KP modifier to the date service line associated with the first medication administration service (H0020) delivered during a service week. The KP modifier is necessary to receive the enhanced payment for the 1st day payment for the first medication administration service delivered during the service week. Only the first weekly threshold Medication administration service (H0020) during each service week should be coded with the KP modifier. H0033 Oral Medication administration direct observation - all other oral medications Intramuscular Injection NOTE: When service includes dispensing Buprenorphine, programs submit a separate claim using the dosage indicated Buprenorphine rates codes indicated on page 45 of this manual. Category Specific Medicaid Billing Limitations Programs may bill for only one medication administration service per day for single or multiple oral medications. When an injectable medication is ordered, a second medication administration service may be billed for this additional administration. However, Medication administration is exempt from the two service per day rule. For example, if a patient receives an Individual, a Group and a Medication Administration and Observation service on the same visit date the program may submit a claim that codes to all three services. When a delivered service includes dispensing Buprenorphine, OASAS certified OTP programs will use the existing dosage banded Buprenorphine rates codes as more fully described in the APG billing section of this manual. 15
16 APG Service Category: Medication Management Routine Time Requirements Time Minimum of 10 minutes Delivering Staff Prescribing professional as defined in Part 822 (working within their scope of practice) Service Definitions Face- to -face visit with a prescribing professional for the purpose of evaluation, monitoring, and management of prescribed medication. Clinical Guidance Routine medication management involves the patient who has already been started on a medication and adjustment or monitoring of the medication needs to occur. A brief history is taken to determine: if the patient is taking the medication as directed if the patient is doing well on the medication if there have been any adverse effects of the medication if the patient has been put on any other medications by other practitioner if the medical/addiction history has changed (use, abstinence, etc) Small changes in the regimen can be suggested and a note is written. A prescription is usually written as well noting a change in dose or continuation of the dose. Documentation: A note signed by a prescribing professional with the time of the visit, summary of the medication management service, results of the service and the plan for treatment should be written in the patient record. APG CPT /HCPCS Billing Code Visit for Drug Monitoring Psychotropic (includes all addiction medicine, including, but not limited to Methadone). Effective 01/01/2015, an E&M code (New Patient), (Existing Patient) must be used to bill for this service. The E&M code selected for billing is based on the complexity of the client. The reimbursement will pivot off of the diagnosis code shown on the claim. **NOTE E&M codes and are for services that can be provided by non-prescribing professionals. By rule for Medication Management Service reimbursement, it must be provided by a prescribing professional. Category Specific Medicaid Billing Limitations Programs may bill for only one medication management service per day. However, Medication management routine as a service is exempt from the cumulative two services per day claim rule. For example, if a patient receives an individual, a group and a Medication management routine service on the same visit date the program may submit a claim that codes to all three services. 16
17 APG Service Category Medication Management Complex Time Requirements: Minimum of 15 minutes Delivering Staff Prescribing professional as defined in Part 822 (working within their scope of practice) Service Definitions Face-to-face service for the purpose of a comprehensive medication review for a new or complex patient. Clinical Guidance This service category is used for non-routine medication management for new patients or patients who are currently taking prescribed medications. Medication Management Complex describes in-depth management of psychopharmacologic agents that have potentially serious side effects. This service involves skilled pharmacologic assessment and clinical decision-making and should not be used to bill a brief evaluation ex, a brief visit for purposes of status review for a prescription renewal. Pharmacologic Management is, by definition, included in an E&M service and, therefore, procedure code may not be billed in addition to any E&M code (e.g., 99213) on the claim. If pharmacologic management and psychotherapy with an E&M (i.e., 90805, 90807, 90809) are both provided on the same date of service (DOS), the pharmacological management is included in the E&M services and may not be billed separately for the same DOS. Documentation: A note signed by the prescribing professional providing the service with the time of the visit, date and duration of the visit and summary of the medication management service, results of the service and the plan for treatment should be written in the patient record. APG CPT /HCPCS Billing Code Effective 01/01/2013, an E&M code ( (New Patient), (Existing Patient)) must be used to bill for this service. The E&M code selected for billing is based on the complexity of the client. The reimbursement will pivot off of the diagnosis code shown on the claim. **NOTE E&M codes and are for services that can be provided by non-prescribing professionals. By rule for Medication Management Service reimbursement, it must be provided by a prescribing professional. Category Specific Medicaid Billing Limitations Programs may bill for only one medication management service per day. However, Medication Management Complex as a service is exempt from the cumulative two service per day claim rule. For example, if a patient receives an individual, a group and a Medication Management Complex service on the same visit date the program may submit a claim that codes to all three services. 17
18 APG Service Category Addiction Medication Induction / Withdrawal Management Time Requirements: Minimum of 30 minutes (may be combined practitioner time on same visit date) Delivering Staff Prescribing professional must direct the induction of addiction medication, medical staff working within the scope of their practice, may provide observation and monitoring of throughout the induction. Service Definitions Face-to-face service for the purpose of induction to a new medication requiring a period of patient observation. Clinical Guidance Complex medication management involves the new patient who is being considered for induction on an addiction medication, or the follow up of a patient to be induced on an addiction medication after the initial evaluation. The service may be used for starting suboxone; methadone; and, other addiction medicine where this level of observation is clinically indicated. The visit should include: a comprehensive medical/psych and addiction history limited assessment of physical/health problems tailored to the addiction patient a decision as to what the next course of action will be as far as using an addiction medication possible alternatives should be discussed. linkage to behavioral treatment, as clinically appropriate for the individual patient is mandatory discussion with the patient as to the use of the medication, expected effects, possible adverse effects possible institution of a contract between practitioner and patient possible ordering of laboratory testing to determine the presence of adverse medical issues that the medication could impact negatively. induction/follow up to the initial visit expanded problem focused/brief review of history including events that occurred between the initial visit and the present visit. Expanded problem focused physical exam if indicated For buprenorphine, Clinical Opiate Withdrawal Scale (COWS) would be used to determine the presence of withdrawal, which will include vital signs. Review of medication with the patient Administration or self-administration of medication direct observation of the patient (time required will vary with the specific medication) Reassess the patient and plan for return to the clinic for further refinement of the medication dose Counselor and/or practitioner engagement of the clinic especially in the behavioral component of the treatment 18
19 Ancillary Withdrawal Services For programs that wish to provide ancillary withdrawal services in an outpatient setting (Part and Part 822-5) please see the related requirements at Documentation A note signed by the prescribing professional providing the service in the patient record including the duration and date of the visit, summary of the medication management service, results of the service and the plan for treatment should be written and placed in the patient record. APG CPT /HCPCS Billing Code H0014 Alcohol and/or drug services Ambulatory Detoxification Category Specific Medicaid Billing Limitations Programs may bill for only one medication management service per day. However, Addiction Medication Induction as a service is exempt from the cumulative two service per day claim rule. For example, if a patient receives an individual, a group and an Addiction Medication Induction service on the same visit date the program may submit a claim that codes to all three services. 19
20 APG Service Category: Admission Assessment Time Requirements Time: Brief 15-minute minimum / Normative 30 minute minimum / Extended 75 minute minimum Delivering Staff Clinical staff (includes medical staff) as defined in part 822 (working within their scope of practice). The extended session may be comprised of 75 minutes of continuous time with multiple staff. Definitions A face-to-face pre-admission service, between a prospective patient and a clinical staff member for the purpose of determining a preliminary diagnosis and initial plan of treatment including the type of services and level of care determination. Clinical Guidance The assessment process has two primary purposes, gathering patient information and history to determine the need for and likelihood of success in outpatient treatment, and the engagement of the patient in the treatment process. The gathering of patient information involves skillful interviewing of the patient, the review of records, conversations with referral sources and may include interviews with collateral contacts. Through the assessment process, the clinical staff person must evaluate data to support a Psychoactive Substance Use Disorder based on DSM (Diagnostic and Statistical Manual) of Mental Disorders or ICD (International Classification of Diseases) criteria. Through the assessment process, the clinical staff person should determine the appropriate level of care for the patient including the appropriate level of intensity for the patient. Beginning April 1, 2015, Chapter 41 of the Laws of 2014 requires insurers to use the OASAS LOCATDR 3.0 tool or other tool approved by OASAS to make SUD level of care decisions. Plans that would like to use a tool other than LOCATDR 3.0 must submit that tool to OASAS General Counsel Rob Kent for approval. Beginning October 1, 2015, all SUD services overseen by Medicaid Managed Care (MMC) New York City plans and those plans MUST use the OASAS LOCATDR 3.0 tool. All MMC plans and providers throughout the rest of state MUST use the LOCADTR 3.0 tool as all SUD benefits transition to managed care July 1, In the interim, MMC plans should not use any fail first rules when making level of care decisions (i.e. requiring a plan member to fail at outpatient or other treatment before they are allowed to access inpatient or residential treatment). Assessment of Physical Health An assessment of physical health and medical history is required as a part of the comprehensive evaluation. If Medical staff meet with the patient prior to admission to gather medical history and identify any physical health problems to be addressed in treatment, this assessment should be billed as an admission assessment visit. If this assessment occurs after admission to treatment, it may be billed as an individual session. E/M codes should only be used when the focus of the session is for a specific medical screening, intervention or treatment service. APG Service Category: Admission Assessment (Continued) Documentation: Along with the information required for the pre-admission assessment a progress note including the date and duration of the service, signed by the clinical staff member delivering the assessment service, describing the assessment visit, results and plan for next steps should be written and placed in the patient s case record. APG CPT /HCPCS Billing Code 20
21 Brief Assessment 15 min minimum T1023 To determine the appropriateness of an individual s participation in a specific program Normative 30 min minimum H0001 Alcohol and/or drug assessment Extended 75 min minimum H0002 Behavioral Health Screening to determine eligibility for admission Category Specific Medicaid Billing Limitations Programs may only bill for one assessment visit per day. Programs may bill for up to three assessment visits prior to admission and per episode of care. Only one of those visits can be billed as an extended assessment visit. In no case should a program bill for more than one extended assessment visit within an episode of care. Medicare / Medicaid and use of CPT codes In those instances where a patient is dually enrolled in Medicaid /Medicare and the service is delivered by a Medicare reimbursable practitioner the program may bill using a CPT code that corresponds to the service delivered AND the associated APG service category and weight: Brief Assessment 15 min minimum Use HCPCS T1023 Normative 30 min minimum Use HCPCS H0001 Alcohol and/or drug assessment Extended 75 min minimum CPT for dates of service 1/1/2013 forward Use of the Physician Fee Schedule - When the physician provides the admission assessment service he/she can bill a separate Physician Fee claim to increase the payment for the service to account for the additional cost for the service provider. However as an alternative, OASAS has implemented the use of a modifier. This replaces the separate Professional claim (837P) that was previously used to obtain the enhanced physician add-on reimbursement. Effective January 1, 2014, providers, whose physicians provide the entire: assessment, individual counseling or group counseling service, may bill using the modifier AG to obtain the enhanced physician add-on reimbursement. The enhanced add-on claim submission can only be billed when a physician provides a service typically provided by clinical staff and is limited to assessment, individual counseling and group counseling services. The current physician billing rule remains in place. Physicians cannot bill for a medication management visit on the same visit date that a qualified physician modifier add-on clinical service is provided. Providers will report the AG modifier on the appropriate individual line level of coding on their claim for the service in which the physician provided the entire service of: assessment, individual counseling or group counseling using the appropriate CPT/HCPCS code for the service provided and the AG modifier on that line of coding. Go to for claiming instructions. This may only occur if the physician provides a service typically provided by clinical staff. This includes individual counseling and group counseling. It excludes medication management services. Physicians cannot bill for a medication management visit on the same day that they bill for a physician fee schedule add on for counseling. 21
22 APG Service Category: Individual Counseling Time Requirements Brief 25 minute / Normative 45 minute Delivering Staff Clinical staff (including medical staff) as defined in Part 822 (working within their scope of practice) Definitions A face-to-face visit between a clinical staff member and an admitted patient focused on the chemical dependency needs of the patient consistent with the treatment / recovery plan, its development, or emergent issues. Clinical Guidance This is a face-to-face session focused on attainment of the goals and objectives identified in the treatment / recovery plan. The counseling should be provided by a clinical staff member and based on accepted counseling theory and practice. The clinician is responsible to learn about evidence-based practices shown to have efficacy with chemical use disorders and should be provided adequate supervision to competently provide this complex service. Each visit should address material relevant to the treatment / recovery plan and document progress toward goals identified in the plan or emergent material identified by the patient. Sessions may include the patient and the admitted significant other; an admitted or non- admitted family member (collateral) and such session should be billed using these codes. If the clinical staff is meeting with family members without the patient present, the visit should be billed as a collateral visit and is subject to the billing rules associated with the collateral service category. Documentation: A progress note including the duration of the visit, signed by the clinical staff member delivering the counseling service. The note must include what the clinician did, how the patient responded, and plan for next steps. APG CPT /HCPCS Billing Code Individual Brief 25 min minimum G0396 Alcohol and/or Substance Abuse Service Individual Normative 45 min minimum G0397 Alcohol and/or Substance Abuse Service 22
23 Medicare / Medicaid and use of CPT codes In those instances where a patient is dually enrolled in Medicaid /Medicare and the service and practitioner are reimbursable by Medicare the program may bill using a CPT code that corresponds to the service delivered AND the associated APG service category and weight: Individual Brief 25 min minimum CPT for dates of service 1/1/2013 forward Individual Normative 45 min minimum CPT for dates of service 1/1/2013 forward Category Specific Medicaid Billing Limitations Programs may not bill for more than one individual counseling service per day. Use of the Physician Fee Schedule - When the physician provides a counseling service he/she can bill a separate Physician Fee claim to increase the payment for the service to account for the additional cost for the service provider. However as an alternative, OASAS has implemented the use of a modifier. This replaces the separate Professional claim (837P) that was previously used to obtain the enhanced physician add-on reimbursement. Effective January 1, 2014, providers, whose physicians provide the entire: assessment, individual counseling or group counseling service, may bill using the modifier AG to obtain the enhanced physician add-on reimbursement. The enhanced add-on claim submission can only be billed when a physician provides a service typically provided by clinical staff and is limited to assessment, individual counseling and group counseling services. The current physician billing rule remains in place. Physicians cannot bill for a medication management visit on the same visit date that a qualified physician modifier add-on clinical service is provided. Providers will report the AG modifier on the appropriate individual line level of coding on their claim for the service in which the physician provided the entire service of: assessment, individual counseling or group counseling using the appropriate CPT/HCPCS code for the service provided and the AG modifier on that line of coding. Go to for claiming instructions. This may only occur if the physician provides a service typically provided by clinical staff. This includes individual counseling and group counseling. It excludes medication management services. Physicians cannot bill for a medication management visit on the same day that they bill for a physician fee schedule add on for counseling. 23