Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.21-007 - Extension of Benefits for Acute Crisis Units and Substance Abuse Detoxification and Telemedicine for Specific Services

Current through Register Vol. 49, No. 6, June, 2024
Outpatient Behavioral Health Services Section
				II
TOC not required
252.111
Individual Behavioral Health
			 Counseling 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90832, U4
90834, U4
90837, U4
90832, U4, U5 - Substance Abuse
90834, U4, U5 - Substance Abuse
90837, U4, U5 - Substance Abuse
90832, UC, UK, U4 - Under Age 4
90834, UC, UK, U4 - Under Age 4
90837, UC, UK, U4 - Under Age 4
90832: psychotherapy, 30 min
90834: psychotherapy, 45 min
90837: psychotherapy, 60 min
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Individual Behavioral Health Counseling is a
							 face-to-face treatment provided to an individual in an outpatient setting for
							 the purpose of treatment and remediation of a condition as described in the
							 current allowable DSM. The treatment service must reduce or alleviate
							 identified symptoms related to either (a) Mental Health or (b) Substance Abuse,
							 and maintain or improve level of functioning, and/or prevent deterioration.
							 Additionally, tobacco cessation counseling is a component of this
							 service.
- Date of Service
- Start and stop times of face-to-face encounter with
							 beneficiary
- Place of service
- Diagnosis and pertinent interval history
- Brief mental status and observations
- Rationale and description of the treatment used
							 that must coincide with Mental Health Diagnosis
- Beneficiary's response to treatment that includes
							 current progress or regression and prognosis
- Any revisions indicated for the diagnosis, or
							 medication concerns
- Plan for next individual therapy session, including
							 any homework assignments and/or advanced psychiatric directive or crisis
							 plans
- Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
Services provided must be congruent with the
							 objectives and interventions articulated on the most recent Mental Health
							 Diagnosis. Services must be consistent with established behavioral healthcare
							 standards. Individual Psychotherapy is not permitted with beneficiaries who do
							 not have the cognitive ability to benefit from the service.
90832: 30 minutes
90834: 45 minutes
90837: 60 minutes
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE
							 BILLED:
One (1) encounter between all three (3) codes.
YEARLY MAXIMUM OF ENCOUNTERS THAT
This service is not for beneficiaries under four (4)
							 years of age except in documented exceptional cases. This service will require
							 a Prior Authorization for beneficiaries under four (4) years of
							 age.
MAY BE BILLED (extension of benefits can be
							 requested):
Counseling Level Beneficiary: Twelve (12) encounters
							 between all three (3) codes
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
Residents of Long-Term Care Facilities
A provider may only bill one (1) Individual
							 Behavioral Health Counseling Code per day per beneficiary. A provider cannot
							 bill any other Individual Behavioral Health Counseling Code on the same date of
							 service for the same beneficiary. For Counseling Level Beneficiaries, there are
							 twelve (12) total individual counseling encounters allowed per year regardless
							 of code billed for Individual Behavioral Health Counseling, unless an extension
							 of benefits is allowed by the Quality Improvement Organization contracted with
							 Arkansas Medicaid.
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE (POS)
- Independently Licensed Clinicians -
							 Master's/Doctoral
- Non-independently Licensed Clinicians -
							 Master's/Doctoral
- Advanced Practice Nurses
- Physicians
- Providers of services for beneficiaries under four
							 (4) years of age must be trained and certified in specific evidence-based
							 practices to be reimbursed for those services
* Independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
* Non-independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49
							 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community
							 Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility),
							 71 (Public Health Clinic), 72 (Rural Health Clinic)
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90853, U4
90853, U4, U5 - Substance Abuse
Group psychotherapy (other than of a multiplefamily
							 group)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Group Behavioral Health Counseling is a face-to-face
							 treatment provided to a group of beneficiaries. Services leverage the emotional
							 interactions of the group's members to assist in each beneficiary's treatment
							 process, support their rehabilitation effort, and to minimize relapse. Services
							 pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition,
							 or both. Additionally, tobacco cessation counseling is a component of this
							 service.
Services must be congruent with the age and abilities
							 of the beneficiary, client-centered, and strength-based; with emphasis on needs
							 as identified by the beneficiary and provided with cultural
							 competence.
* Date of Service
* Start and stop times of actual group encounter that
							 includes identified beneficiary
* Place of service
* Number of participants
* Diagnosis
* Focus of group
* Brief mental status and observations
* Rationale for group counseling must coincide with
							 Mental Health Assessment
* Beneficiary's response to the group counseling that
							 includes current progress or regression and prognosis
* Any changes indicated for diagnosis, or medication
							 concerns
* Plan for next group session, including any homework
							 assignments or crisis plans, or both
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
This does NOT include psychosocial groups.
							 Beneficiaries eligible for Group Behavioral Health Counseling must demonstrate
							 the ability to benefit from experiences shared by others, the ability to
							 participate in a group dynamic process while respecting the others' rights to
							 confidentiality and must be able to integrate feedback received from other
							 group members. For groups of beneficiaries eighteen (18) years of age and over,
							 the minimum number that must be served in a specified group is two (2). The
							 maximum that may be served in a specified group is twelve (12). For groups of
							 beneficiaries under eighteen (18) years of age, the minimum number that must be
							 served in a specified group is two (2). The maximum that may be served in a
							 specified group is ten (10). A beneficiary must be four (4) years of age to
							 receive group therapy. Group treatment must be age and developmentally
							 appropriate, (i.e., sixteen (16) year-olds and four (4) year-olds must not be
							 treated in the same group). Providers may bill for services only at times
							 during which beneficiaries participate in group activities.
Encounter
DAILY MAXIMUM OF
ENCOUNTERS THAT MAY BE BILLED: One (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested):
Counseling Level Beneficiary: Twelve (12)
							 encounters
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
A provider can only bill one (1) Group Behavioral
							 Health Counseling encounter per day. For Counseling Level Beneficiaries, there
							 are twelve (12) total group behavioral health counseling encounters allowed per
							 year, unless an extension of benefits is allowed by the Quality Improvement
							 Organization contracted with Arkansas Medicaid.
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, eighteen (18) years of age and
							 above)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians -
							 Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
02 (Telemedicine), 03 (School), 11 (Office), 49
							 (Independent Clinic), 49 (Independent Clinic), 50 (Federally Qualified Health
							 Center), 53 (Community Mental Health Center), 57 (Non-Residential Substances
							 Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health
							 Clinic)
252.113
Marital/Family Behavioral Health Counseling with Beneficiary Present
			 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90847, U4 90847, U4, U5 - Substance Abuse
90847, UC, UK, U4 - Dyadic Treatment *
Family psychotherapy (conjoint psychotherapy) (with
							 patient present)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Marital/Family Behavioral Health Counseling with
							 Beneficiary Present is a face-to-face treatment provided to one (1) or more
							 family members in the presence of a beneficiary. Services are designed to
							 enhance insight into family interactions, facilitate inter-family emotional or
							 practical support and to develop alternative strategies to address familial
							 issues, problems, and needs. Services pertain to a beneficiary's (a) Mental
							 Health or (b) Substance Abuse condition, or both. Additionally, tobacco
							 cessation counseling is a component of this service.
Services must be congruent with the age and abilities
							 of the beneficiary, client-centered, and strength-based; with emphasis on needs
							 as identified by the beneficiary and provided with cultural
							 competence.
* Date of Service
* Start and stop times of actual encounter with
							 beneficiary and spouse/family
* Place of service
* Participants present and relationship to
							 beneficiary
* Diagnosis and pertinent interval history
* Brief mental status of beneficiary and observations
							 of beneficiary with spouse/family
* Rationale, and description of treatment used must
							 coincide with the Mental Health Diagnosis and improve the impact the
							 beneficiary's condition has on the spouse/family or improve marital/family
							 interactions between the beneficiary and the spouse/family, or both
*Dyadic treatment is available for
							 parent/caregiver and child for dyadic treatment of children who are from zero
							 through forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment
							 must be prior authorized and is only available for beneficiaries in Tier One
							 (1). Dyadic Infant/Caregiver Psychotherapy is a behaviorally based therapy that
							 involves improving the parent-child relationship by transforming the
							 interaction between the two parties. The primary goal of Dyadic Infant/Parent
							 Psychotherapy is to strengthen the relationship between a child and his or her
							 parent (or caregiver) as a vehicle for restoring the child's sense of safety,
							 attachment, and appropriate affect and improving the child's cognitive,
							 behavioral, and social functioning. This service uses child directed
							 interaction to promote interaction between the parent and the child in a
							 playful manner. Providers must utilize a nationally recognized evidence-based
							 practice. Practices include, but are not limited to, Child-Parent Psychotherapy
							 (CPP) and Parent Child Interaction Therapy (PCIT).
**Dyadic treatment by telemedicine must
							 continue to assure adherence to the evidence-based protocol for the treatment
							 being provided, i.e. PCIT would require a video component sufficient for the
							 provider to be able to see both the parent and child, have a communication
							 device (ear phones, ear buds, etc.) to enable the provider to communicate
							 directly with the parent only while providing directives related to the
							 parent/child interaction.
* Beneficiary and spouse/family's response to
							 treatment that includes current progress or regression and prognosis
* Any changes indicated for the diagnosis, or
							 medication concerns
* Plan for next session, including any homework
							 assignments or crisis plans, or both
* Staff signature/credentials/date of
							 signature
* HIPAA compliant Release of Information, completed,
							 signed, and dated
NOTES
UNIT
BENEFIT LIMITS
Natural supports may be included in these sessions if
							 justified in service documentation and if supported in the documentation in the
							 Mental Health Diagnosis. Only one (1) beneficiary per family, per therapy
							 session, may be billed.
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested):
Counseling Level
Beneficiaries: Twelve (12) encounters
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
A provider can only bill one (1) Marital/Family
							 Behavioral Health Counseling with (or without) Patient encounter per day. There
							 are twelve (12) total Marital/Family Behavioral Health Counseling with
							 Beneficiary Present encounters allowed, per year, unless an extension of
							 benefits is allowed by the Quality Improvement Organization contracted with
							 Arkansas Medicaid.
The following codes cannot be billed on the
							 Same Date of Service:
90849 - Multi-Family Behavioral Health
							 Counseling
90846 - Marital/Family Behavioral Health Counseling
							 without Beneficiary Present
H2027 -- Psychoeducation
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians
							 -Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
* Providers of dyadic services must be trained and
							 certified in specific evidence-based practices to be reimbursed for those
							 services
* Independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
* Non-independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90846, U4
90846, U4, U5 - Substance Abuse
90846, U4, U5 - Substance Abuse,
							 Telemedicine
Family psychotherapy (without the patient
							 present)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Marital/Family Behavioral Health Counseling without
							 Beneficiary Present is a face-to-face treatment provided to one or more family
							 members outside the presence of a beneficiary. Services are designed to enhance
							 insight into family interactions, facilitate inter-family emotional or
							 practical support, and develop alternative strategies to address familial
							 issues, problems, and needs. Services pertain to a beneficiary's (a) Mental
							 Health or (b) Substance Abuse condition, or both. Additionally, tobacco
							 cessation counseling is a component of this service.
Services must be congruent with the age and abilities
							 of the beneficiary or family member(s), client-centered, and strength-based;
							 with emphasis on needs as identified by the beneficiary and family and provided
							 with cultural competence.
* Date of Service
* Start and stop times of actual encounter
							 spouse/family
* Place of service
* Participants present and relationship to
							 beneficiary
* Diagnosis and pertinent interval history
* Brief observations with spouse/family
* Rationale, and description of treatment used must
							 coincide with the Mental Health Diagnosis and improve the impact the
							 beneficiary's condition has on the spouse/family, or improve marital/family
							 interactions between the beneficiary and the spouse/family, or both
* Beneficiary and spouse/family's response to
							 treatment that includes current progress or regression and prognosis
* Any changes indicated for the diagnosis, or
							 medication concerns
* Plan for next session, including any homework
							 assignments or crisis plans, or both
* Staff signature/credentials/date of
							 signature
* HIPAA compliant Release of Information, completed,
							 signed, and dated
NOTES
UNIT
BENEFIT LIMITS
Natural supports may be included in these sessions,
							 if justified in service documentation, and if supported in Mental Health
							 Diagnosis. Only one (1) beneficiary per family per therapy session may be
							 billed.
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested):
Counseling Level
Beneficiaries: Twelve (12) encounters
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
A provider can only bill one (1) Marital/Family
							 Behavioral Health Counseling with (or without) Beneficiary encounter per
							 day.
The following codes cannot be billed on the
							 Same Date of Service:
90849 - Multi-Family Behavioral Health
							 Counseling
90847 - Marital/Family Behavioral Health Counseling
							 with Beneficiary Present
H2027 -- Psychoeducation
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians
							 -Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
H2027, U4
H2027, UK, U4 - Dyadic Treatment*
Psychoeducational service; per fifteen (15)
							 minutes
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Psychoeducation provides beneficiaries and their
							 families with pertinent information regarding mental illness, substance abuse,
							 and tobacco cessation, and teaches problemsolving, communication, and coping
							 skills to support recovery. Psychoeducation can be implemented in two (2)
							 formats: multifamily group and/or single-family group. Due to the group format,
							 beneficiaries and their families are also able to benefit from support of peers
							 and mutual aid. Services must be congruent with the age and abilities of the
							 beneficiary, client-centered, and strength-based; with emphasis on needs as
							 identified by the beneficiary and provided with cultural
							 competence.
* Date of Service
* Start and stop times of actual encounter with
							 beneficiary and spouse/family
* Place of service
* Participants present
* Nature of relationship with beneficiary
* Rationale for excluding the identified
							 beneficiary
* Diagnosis and pertinent interval history
* Rationale and objective used must
							 coincide
*Dyadic treatment is available for
							 parent/caregiver and child for dyadic treatment of children from zero through
							 forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment must be
							 prior authorized. Providers must utilize a national recognized evidencebased
							 practice. Practices include, but are not limited to, Nurturing Parents and
							 Incredible Years.
with Mental Health Diagnosis and improve the impact
							 the beneficiary's condition has on the spouse/family or improve marital/family
							 interactions between the beneficiary and the spouse/family, or both
* Spouse/family response to treatment that
includes current progress or regression and
							 prognosis
* Any changes indicated for the diagnosis, or
							 medication concerns
* Plan for next session, including any homework
							 assignments or crisis plans, or both
* HIPAA compliant Release of Information forms,
							 completed, signed, and dated
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
Information to support the appropriateness of
							 excluding the identified beneficiary must be documented in the service note and
							 medical record. Natural supports may be included in these sessions when the
							 nature of the relationship with the beneficiary and that support's expected
							 role in attaining treatment goals is documented. Only one (1) beneficiary per
							 family per therapy session may be billed.
Fifteen (15) minutes
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: Four
							 (4)
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
							 of benefits can be requested): forty-eight (48)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
A provider can only bill a total of forty-eight (48)
							 units of Psychoeducation
The following codes cannot be billed on the
							 Same Date of Service:
90847 - Marital/Family Behavioral Health Counseling
							 with Beneficiary Present
90846 - Marital/Family Behavioral Health Counseling
							 without Beneficiary Present
H2027 -- Psychoeducation
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians
							 -Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurse
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72
* Physician
* Providers of dyadic services must be trained and
							 certified in specific evidence-based practices to be reimbursed for those
							 services
* Independently Licensed Clinicians -Parent/Caregiver
							 and Child (Dyadic treatment of Children from zero through forty-seven (0-47)
							 months of age and Parent/Caregiver) Provider
* Non-independently Licensed Clinicians
							 -Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
(Rural Health Clinic)
252.117
Mental Health Diagnosis 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90791, U4
90791, UC, UK, U4 - Dyadic Treatment *
Psychiatric diagnostic evaluation (with no medical
							 services)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Mental Health Diagnosis is a clinical service for the
							 purpose of determining the existence, type, nature, and appropriate treatment
							 of a mental illness, or related disorder, as described in the current allowable
							 DSM. This service may include time spent for obtaining necessary information
							 for diagnostic purposes. The psychodiagnostics process may include, but is not
							 limited to: a psychosocial and medical history, diagnostic findings, and
							 recommendations. This service must include a face-to-face or telemedicine
							 component and will serve as the basis for documentation of modality and issues
							 to be addressed (plan of care). Services must be congruent with the age and
							 abilities of the beneficiary, client-centered, and strength-based; with
							 emphasis on needs as identified by the beneficiary and provided with cultural
							 competence.
* Date of Service
* Start and stop times of the face-to-face encounter
							 with the beneficiary and the interpretation time for diagnostic
							 formulation
* Place of service
* Identifying information
* Referral reason
* Presenting problem(s), history of presenting
							 problem(s) including duration, intensity, and response(s) to prior
							 treatment
* Culturally and age-appropriate psychosocial history
							 and assessment
* Mental status (Clinical observations and
							 impressions)
* Current functioning plus strengths and needs in
							 specified life domains
* DSM diagnostic impressions
* Treatment recommendations and prognosis for
							 treatment
* Goals and objectives to be placed in Plan of
							 Care
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
This service may be billed for face-to-face contact
							 as well as for time spent obtaining necessary information for diagnostic
							 purposes; however, this time may NOT be used for development or submission of
							 required paperwork processes
This service can be provided via telemedicine.
*Dyadic treatment is available for
							 parent/caregiver and child for dyadic treatment of children from zero through
							 forty-seven (0-47) months of age and parent/caregiver. A Mental Health
							 Diagnosis will be required for all children through forty-seven (47) months of
							 age to receive services. This service includes up to four (4) encounters for
							 children through the age of forty-seven (47) months of age and can be provided
							 without a prior authorization. This service must include an assessment
							 of:
*
Presenting symptoms and
							 behaviors
*
Developmental and medical
							 history
*
Family psychosocial and medical
							 history
*
Family functioning, cultural and
							 communication patterns, and current environmental conditions and
							 stressors
*
Clinical interview with the primary caregiver
							 and observation of the caregiver-infant relationship and interactive patterns
							 and
*
Child's affective, language, cognitive,
							 motor, sensory, selfcare, and social functioning
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested): One (1)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
Residents of Long-Term Care
The following codes cannot be billed on
							 the
Same Date of Service:
90792 - Psychiatric Assessment
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDER
PLACE OF SERVICE
* Independently Licensed Clinicians
* Master's/Doctoral
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49
							 (Independent Clinic), 50
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
* Providers of dyadic services must be trained and
							 certified in specific evidence-based practices to be reimbursed for those
							 services
* Independently Licensed Clinicians
* Parent/Caregiver and Child (Dyadic treatment of
							 Children from zero through forty-seven (0-47) months of age and
							 Parent/Caregiver) Provider
* Non-independently Licensed Clinicians
* Parent/Caregiver and Child (Dyadic treatment of
							 Children from zero through forty-seven (0-47) months of age and
							 Parent/Caregiver) Provider
(Federally Qualified Health Center), 53 (Community
							 Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility),
							 71 (Public Health Clinic), 72 (Rural Health Clinic)
252.118
Interpretation of Diagnosis 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90887, U4
90887, UC, UK, U4 - Dyadic Treatment
Interpretation or explanation of results of
							 psychiatric, other medical examinations and procedures, or other accumulated
							 data, to family or other responsible persons (or advising them how to assist
							 patient)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Interpretation of Diagnosis is a direct service
							 provided for the purpose of interpreting the results of psychiatric or other
							 medical exams, procedures, or accumulated data. Services may include diagnostic
							 activities or advising the beneficiary and their family. Services pertain to a
							 beneficiary's (a) Mental Health or (b) Substance Abuse condition, or both.
							 Consent forms may be required for family or significant other involvement.
							 Services must be congruent with the age and abilities of the beneficiary,
							 client-centered, and strength-based; with emphasis on needs as identified by
							 the beneficiary and provided with cultural competence.
* Start and stop times of face-to-face encounter with
							 beneficiary and/or parent(s) or guardian(s)
* Date of service
* Place of service
* Participants present and relationship to
							 beneficiary
* Diagnosis
* Rationale for and objective used that must coincide
							 with the Mental Health Diagnosis
* Participant(s) response and feedback
* Recommendation for additional supports including
							 referrals, resources, and information
* Staff signature/credentials/date of
							 signature(s)
NOTES
UNIT
BENEFIT LIMITS
For beneficiaries under eighteen (18) years of age,
							 the time may be spent face-to-face with the beneficiary; the beneficiary and
							 the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For
							 beneficiaries over eighteen (18) years of age, the time may be spent
							 face-to-face with the beneficiary and the spouse, legal guardian, or
							 significant other.
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT
This service can be provided via telemedicine to
							 beneficiaries eighteen (18) years of age and above. This service can also be
							 provided via telemedicine to beneficiaries seventeen (17) years of age and
							 under with documentation of parental or guardian involvement during the
							 service. This documentation must be included in the medical record.
*Dyadic treatment is available for
							 parent/caregiver and child for dyadic treatment of children from zero through
							 forty-seven (0-47) months of age and parent/caregiver. Interpretation of
							 Diagnosis will be required in order for all children, through forty-seven (47)
							 months of age, to receive services. This service includes up to four (4)
							 encounters for children through fortyseven (47) months of age and can be
							 provided without a prior authorization. The Interpretation of Diagnosis is a
							 direct service that includes an interpretation from a broader perspective,
							 based on the history and information collected through the Mental Health
							 Diagnosis. This interpretation identifies and prioritizes the infant's needs,
							 establishes a diagnosis, and helps to determine the care and services to be
							 provided.
MAY BE BILLED: One (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested):
Counseling Level Beneficiary: One (1)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
The following codes cannot be billed on the
							 Same Date of Service:
H2027 - Psychoeducation
90792 - Psychiatric Assessment
90849 - Multi-Family Behavioral Health
							 Counseling
H0001 - Substance Abuse Assessment
This service can be provided via telemedicine to
							 beneficiaries eighteen (18) years of age and above. This service can also be
							 provided via telemedicine to beneficiaries seventeen (17) years of age and
							 under with documentation of parental or guardian involvement during the
							 service. This documentation must be included in the medical record.
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine Adults, Youth and
							 Children
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians -
							 Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
* Providers of dyadic services must be trained and
							 certified, in specific evidence-based practices, to be reimbursed for those
							 services
* Independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
* Non-independently Licensed Clinicians -
							 Parent/Caregiver and Child (Dyadic treatment of Children from zero through
							 forty-seven (0-47) months of age and Parent/Caregiver) Provider
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
252.119
Substance Abuse Assessment 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
H0001, U4
Alcohol and/or drug assessment
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Substance Abuse Assessment is a service that
							 identifies and evaluates the nature and extent of a beneficiary's substance
							 abuse condition using the Addiction Severity Index (ASI) or an assessment
							 instrument approved by DAABHS and DMS. The assessment must screen for and
							 identify any existing co-morbid conditions. The assessment should assign a
							 diagnostic impression to the beneficiary, resulting in a treatment
							 recommendation and referral appropriate to effectively treat the condition(s)
							 identified.
Services must be congruent with the age and abilities
							 of the beneficiary, client-centered, and strength-based; with emphasis on
							 needs, as identified by the beneficiary, and provided with cultural
							 competence.
* Date of Service
* Start and stop times of the face-to-face encounter
							 with the beneficiary and the interpretation time for diagnostic
							 formulation
* Place of service
* Identifying information
* Referral reason
* Presenting problem(s), history of presenting
							 problem(s) including duration, intensity, and response(s) to prior
							 treatment
* Cultural and age-appropriate psychosocial history
							 and assessment
* Mental status (Clinical observations and
							 impressions)
* Current functioning and strengths in specified life
							 domains
* DSM diagnostic impressions
* Treatment recommendations and prognosis for
							 treatment
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
The assessment process results in the assignment of a
							 diagnostic impression, beneficiary recommendation for treatment regimen
							 appropriate to the condition and situation presented by the beneficiary,
							 initial plan (provisional) of care, and referral to a service appropriate to
							 effectively treat the condition(s) identified. If indicated, the assessment
							 process must refer the beneficiary for a psychiatric
							 consultation.
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested): One (1)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
The following codes cannot be billed on the
							 Same Date of Service:
90887 - Interpretation of Diagnosis
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians -
							 Master's/Doctoral
* Non-independently Licensed Clinicians -
							 Master's/Doctoral
* Advanced Practice Nurses
* Physicians
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
252.121
Pharmacologic Management 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
99212, UB, U4 - Physician
99213, UB, U4 - Physician
99214, UB, U4 - Physician
99212, SA, U4 - APN
99213, SA, U4 - APN
99212: Office or other outpatient encounter for the
							 evaluation and management of an established patient, which requires at least
							 two (2) of these three (3) key components: A problem focused history; A problem
							 focused examination; or straightforward medical decision making.
99214, SA, U4 - APN
99213: Office or other outpatient encounter for the
							 evaluation and management of an established patient, which requires at least
							 two (2) of these three (3) key components: An expanded problem focused history;
							 An expanded problem-focused examination; or medical decision making of low
							 complexity.
99214: Office or other outpatient encounter for the
							 evaluation and management of an established patient, which requires at least
							 two (2) of these three (3) key components: A detailed history, A detailed
							 examination; or medical decision making of moderate complexity.
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Pharmacologic Management is a service tailored to
							 reduce, stabilize, or eliminate psychiatric symptoms, with the goal of
							 improving functioning, including management and reduction of symptoms. This
							 service includes evaluation of the medication prescription, administration,
							 monitoring, and supervision, as well as informing beneficiaries regarding
							 potential effects and side effects of medication(s), in order to make informed
							 decisions regarding the prescribed medications. Services must be congruent with
							 the age, strengths, and accommodations necessary for disability and cultural
							 framework.
Services must be congruent with the age and abilities
							 of the beneficiary, client-centered, and strength-based; with emphasis on needs
							 as identified by the beneficiary and provided with cultural
							 competence.
* Date of Service
* Start and stop times of actual encounter with
							 beneficiary
* Place of service (When ninety-nine (99) is used for
							 telemedicine, specific locations of the beneficiary, and the physician must be
							 included)
* Diagnosis and pertinent interval history
* Brief mental status and observations
* Rationale for and treatment used that must coincide
							 with the Psychiatric Assessment
* Beneficiary's response to treatment that includes
							 current progress or regression and prognosis
* Revisions indicated for the diagnosis, or
							 medication(s)
* Plan for follow-up services, including any crisis
							 plans
* If provided by physician that is not a
							 psychiatrist, then any off-label uses of medications should include documented
							 consult with the overseeing psychiatrist within twenty-four (24) hours of the
							 prescription being written
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
Applies only to medications prescribed to address
							 targeted symptoms as identified in the Psychiatric Assessment.
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested): Twelve (12)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Advanced Practice Nurse
* Physician
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office), 12 (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
252.122
Psychiatric Assessment 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
90792, U4
Psychiatric diagnostic evaluation with medical
							 services
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Psychiatric Assessment is a face-to-face
							 psychodiagnostics assessment conducted by a licensed physician or Advanced
							 Practice Nurse (APN), preferably one with specialized training and experience
							 in psychiatry (child and adolescent psychiatry for beneficiaries under eighteen
							 (18) years of age). This service is provided to determine the existence, type,
							 nature, and most appropriate treatment of a behavioral health disorder. This
							 service is not required for beneficiaries to receive Counseling Level
							 Services.
* Date of Service
* Start and stop times of the face-to-face encounter
							 with the beneficiary and the interpretation time for diagnostic
							 formulation
* Place of service
* Identifying information
* Referral reason
* The interview should obtain or verify the
							 following:
1. The beneficiary's understanding of the factors
							 leading to the referral
2. The presenting problem (including symptoms and
							 functional impairments)
3. Relevant life circumstances and psychological
							 factors
4. History of problems
5. Treatment history
6. Response to prior treatment interventions
7. Medical history (and examination as
							 indicated)
* For beneficiaries under eighteen (18) years of
							 age
1. an interview of a parent (preferably both), the
							 guardian (including the responsible DCFS caseworker), and the primary caretaker
							 (including foster parents) as applicable in order to:
a) Clarify the reason for the referral
b) Clarify the nature of the current symptoms
c) Obtain a detailed medical, family, and
							 developmental history
* Culturally and age-appropriate psychosocial history
							 and assessment
* Mental status/Clinical observations and
							 impressions
* Current functioning and strengths in specified life
							 domains
* DSM diagnostic impressions
* Treatment recommendations
* Staff signature/credentials/date of
							 signature
NOTES
UNIT
BENEFIT LIMITS
This service may be billed for face-to-face contact
							 as well as for time spent obtaining necessary information for diagnostic
							 purposes; however, this time may NOT be used for development or submission of
							 required paperwork processes (i.e. treatment plans, etc.).
Encounter
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One
							 (1)
YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED
							 (extension of benefits can be requested): One (1)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
Telemedicine (Adults, Youth, and
							 Children)
The following codes cannot be billed on
							 the
Same Date of Service:
90791 - Mental Health Diagnosis
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Counseling
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
A. an Arkansas-licensed physician, preferably one
							 with specialized training and experience in psychiatry (child and adolescent
							 psychiatry for beneficiaries under eighteen (18) years of age)
B. an Adult Psychiatric Mental Health Advanced Nurse
							 Practitioner/Family Psychiatric Mental Health Advanced Nurse Practitioner
							 (PMHNP-BC)
The PMHNP-BC must meet all of the following
							 requirements:
A. Licensed by the Arkansas State Board of
							 Nursing
B. Practicing with licensure through the American
							 Nurses Credentialing Center
C. Practicing under the supervision of an
							 Arkansas-licensed psychiatrist with whom the PMHNP-BC has a collaborative
							 agreement. The findings of the Psychiatric Assessment conducted by the
							 PMHNP-BC, must be discussed with the supervising psychiatrist within forty-five
							 (45) days of the beneficiary entering care. The collaborative agreement must
							 comply with all Board of Nursing requirements and must spell out, in detail,
							 what the nurse is authorized to do and what age group they may treat
D. Practicing within the scope of practice as defined
							 by the Arkansas Nurse Practice Act
E. Practicing within a PMHNP-BC's experience and
							 competency level
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office), 12, (Patient's Home), 49 (Independent Clinic), 50
							 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57
							 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health
							 Clinic), 72 (Rural Health Clinic)
255.001
Crisis Intervention 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
H2011, HA, U4
Crisis intervention service, per fifteen (15)
							 minutes
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Crisis Intervention is unscheduled, immediate,
							 short-term treatment activities provided to a Medicaid-eligible beneficiary who
							 is experiencing a psychiatric or behavioral crisis. Services are to be
							 congruent with the age, strengths, needed accommodation for any disability, and
							 cultural framework of the beneficiary and his/her family. These services are
							 designed to stabilize the person in crisis,
* Date of service
* Start and stop time of actual encounter with
							 beneficiary and possible collateral contacts with caregivers or informed
							 persons
* Place of service
* Specific persons providing pertinent information in
							 relationship to beneficiary
prevent further deterioration and provide immediate
							 indicated treatment in the least restrictive setting. (These activities include
							 evaluating a Medicaid-eligible beneficiary to determine if the need for crisis
							 services is present.)
Services are to be congruent with the age, strengths,
							 needed accommodation for any disability, and cultural framework of the
							 beneficiary and their family.
* Diagnosis and synopsis of events leading up to
							 crisis situation
* Brief mental status and observations
* Utilization of previously established psychiatric
							 advance directive or crisis plan as pertinent to current situation OR rationale
							 for crisis intervention activities utilized
* Beneficiary's response to the intervention that
							 includes current progress or regression and prognosis
* Clear resolution of the current crisis and/or plans
							 for further services
* Development of a clearly defined crisis plan or
							 revision to existing plan
* Staff signature/credentials/date of
							 signature(s)
NOTES
UNIT
BENEFIT LIMITS
A psychiatric or behavioral crisis is defined as an
							 acute situation, in which an individual is experiencing a serious mental
							 illness or emotional disturbance to the point that the beneficiary or others
							 are at risk for imminent harm, or in which to prevent significant deterioration
							 of the beneficiary's functioning.
This service can be provided to beneficiaries that
							 have not been previously assessed or have not previously received behavioral
							 health services.
The provider of this service MUST complete a Mental
							 Health Diagnosis (90791) within seven (7) days of provision of this service, if
							 provided to a beneficiary who is not currently a client. If the beneficiary
							 cannot be contacted or does not return for a Mental Health Diagnosis
							 appointment, attempts to contact the beneficiary must be placed in the
							 beneficiary's medical record. If the beneficiary needs more time to be
							 stabilized, this must be noted in the beneficiary's medical record and the
							 Division of Medical Services Quality Improvement Organization (QIO) must be
							 notified.
Fifteen (15) minutes
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: twelve
							 (12)
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
							 of benefits can be requested): seventy-two (72)
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children, Youth, and Adults
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
Telemedicine (Adults, Youth, and
							 Children)
Crisis
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
* Independently Licensed Clinicians -
							 Master's/Doctoral
02 (Telemedicine), 03 (School), 04 (Homeless
							 Shelter), 11 (Office) 12 (Patient's Home), 15
* Non-independently Licensed Clinicians -
							 Master's/Doctoral (must be employed by Behavioral Health Agency)
* Advanced Practice Nurses
* Physicians (must be employed by Behavioral Health
							 Agency)
(Mobile Unit), 23 (Emergency Room), 33 (Custodial
							 Care facility), 49 (Independent Clinic), 50 (Federally Qualified Health
							 Center), 53 (Community Mental Health Center), 57( Non-Residential Substance
							 Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic),
							 99 (Other Location)
255.003
Acute Crisis Units 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
H0018, U4
Behavioral Health; short-term residential
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Acute Crisis Units provide brief (96 hours or less)
							 crisis treatment services to persons eighteen (18) years of age and over, who
							 are experiencing a psychiatric- or substance abuse-related crisis, or both, and
							 may pose an escalated risk of harm to self or others. Acute Crisis Units
							 provide hospital diversion and stepdown services in a safe environment with
							 psychiatry and substance abuse services onsite at all times, as well as on-call
							 psychiatry available twenty-four (24) hours a day. Services provide ongoing
							 assessment and observation; crisis intervention; psychiatric, substance, and
							 co-occurring treatment; and initiate referral mechanisms for independent
							 assessment and care planning as needed.
NOTES
EXAMPLE ACTIVITIES
APPLICABLE POPULATIONS
UNIT
BENEFIT LIMITS
Adults
Per Diem
* Ninety-six (96) hours or less per admission;
							 Extension of Benefits required for additional days
PROGRAM SERVICE CATEGORY
Crisis Services
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
N/A
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
Acute Crisis Units must be certified by
							 the
55 (Residential Substance Abuse Treatment
Division of Provider Services and Quality Assurance
							 as an Acute Crisis Unit Provider.
Facility), 56 (Psychiatric Residential Treatment
							 Center
255.004
Substance Abuse Detoxification 1-1-22
CPT®/HCPCS PROCEDURE
							 CODE
PROCEDURE CODE DESCRIPTION
H0014, U4
Alcohol and/or drug services;
							 detoxification
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION
							 REQUIREMENTS
Substance Abuse Detoxification is a set of
							 interventions aimed at managing acute intoxication and withdrawal from alcohol
							 or other drugs. Services help stabilize beneficiaries by clearing toxins from
							 the beneficiary's body. Services are short-term and may be provided in a crisis
							 unit, inpatient, or outpatient setting, and may include evaluation,
							 observation, medical monitoring, and addiction treatment. Detoxification seeks
							 to minimize the physical harm caused by the abuse of substances and prepares
							 the beneficiary for ongoing treatment.
NOTES
EXAMPLE ACTIVITIES
APPLICABLE POPULATIONS
UNIT
BENEFIT LIMITS
Youth and Adults
N/A
* Six (6) encounters per SFY; Extension of Benefits
							 required for additional encounters
PROGRAM SERVICE CATEGORY
Crisis Services
ALLOWED MODE(S) OF
							 DELIVERY
TIER
Face-to-face
N/A
ALLOWABLE PERFORMING
							 PROVIDERS
PLACE OF SERVICE
Substance Abuse Detoxification must be provided in a
							 facility that is certified by the Division of Provider Services and Quality
							 Assurance as a Substance Abuse Detoxification provider.
55 (Residential Substance Abuse Treatment
							 Facility)
305.000
Telemedicine Billing Guidelines 1-1-22
Telemedicine is defined as the use of electronic information
				and communication technology to deliver healthcare services including without
				limitation, the assessment, diagnosis, consultation, treatment, education, care
				management, and self-management of a patient. Telemedicine includes
				store-and-forward technology and remote patient monitoring. (See policy section
				I.)
Arkansas Medicaid shall provide payment for telemedicine
				healthcare services to licensed or certified healthcare professionals or
				entities that are authorized to bill Arkansas Medicaid directly for healthcare
				services. Coverage and reimbursement for healthcare services provided through
				telemedicine shall be reimbursed on the same basis as healthcare services
				provided in person.
Payment will include a reasonable facility fee to the
				originating site (the site at which the patient is located at the time
				telemedicine healthcare services are provided). In order to receive
				reimbursement, the originating site must be operated by a healthcare
				professional or licensed healthcare entity that is authorized to bill Medicaid
				directly for healthcare services. The distant site is the location of the
				healthcare provider delivering telemedicine services. Services at the distant
				site must be provided by an enrolled Arkansas Medicaid Provider who is
				authorized by Arkansas law to administer healthcare.
Coding Guidelines:
1.
			 The originating site shall submit a telemedicine claim under the billing
			 providers "pay to" information, using HCPCS code Q3014. The code must be
			 submitted for the same date of service as the professional code and must
			 indicate the place of service (where the member was at the time of the
			 telemedicine encounter). Except in the case of hospital facility claims, the
			 provider who is responsible for the care of the member at the originating site
			 shall be entered as the performing provider in the appropriate field of the
			 claim. For outpatient claims that occur in a hospital setting, the provider
			 must also use Place of Service code twenty-two (22) with the originating site
			 billing Q3014. In the case of in-patient services, HCPCS code Q3014 is not
			 separately reimbursable because it is included in the hospital per
			 diem.
2. The provider of the
			 distant site must submit claims for telemedicine services using the appropriate
			 CPT or HCPCS code for the professional service delivered. The provider must use
			 Place of Service two (02) (telemedicine distant site) when billing the CPT or
			 HCPCS codes.
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
				MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS
ATTACHMENT 3.1-A
13. Other diagnostic, screening, preventive and rehabilitative
				services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
3. Outpatient Behavioral Health Services
			 (OBHS)
xxix. Crisis Care - De-escalation*
Eligibility for this service is determined by an Independent
				Assessment and must be prior authorized.
DEFINITION: Crisis Care - De-escalation provides temporary
				direct care for a beneficiary in the beneficiary's community that is not
				facility-based. Crisis Care - De-escalation services de-escalate stressful
				situations and provide a therapeutic outlet. Crisis Care includes behavioral
				interventions that keep beneficiaries in their current situation and reduces
				the need for acute hospitalization or other higher levels of care. Crisis Care
				shall be indicated in the treatment plan.
This service will not be paid for within an Institution for
				Mental Disease (IMD).
This service does not include payment for room and board of the
				beneficiary.
Crisis Care - De-escalation provider must be certified
				by the Department of Human Services as a Crisis Care - De-escalation
				provider.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral
				Health Provider - Non-Degreed.
xxx. Acute Crisis Units*
Definition: Acute Crisis Units provide brief 96 hours or less)
				crisis treatment services to persons over the age of 17 who are experiencing a
				psychiatry and/or substance abuse-related crisis and may pose an escalated risk
				of harm to self or others. Acute Crisis Units provide hospital diversion and
				step-down services in a safe environment with psychiatry and/or substance abuse
				services on-site at all times as well as on-call psychiatry available 24 hours
				a day. Services provide ongoing assessment and observation; crisis
				intervention; psychiatric, substance, and co-occurring treatment; and initiate
				referral mechanisms for independent assessment and care planning as
				needed.
This service will not be paid for within an Institution for
				Mental Disease (IMD).
This service does not include payment for room and board of the
				beneficiary.
Acute Crisis Unit must be certified by Department of
				Human Services as an Acute Crisis Unit.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral
				Health Provider - Non-Degreed.
An Extension of Benefit for medical necessity is
				required for admissions exceeding ninety-six (96) hours.
*All medically necessary 1905(a) services, that correct or
				ameliorate physical and mental illnesses and conditions, are covered for EPSDT
				eligible beneficiaries, ages birth to twenty-one, in accordance with 1905(r) of
				the Social Security Act.
13. Other diagnostic, screening, preventive and rehabilitative
				services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services (continued)
3. Outpatient Behavioral Health Services (OBHS)
xxxi. Crisis Intervention*
DEFINITION: Crisis Intervention is an unscheduled, immediate,
				short-term treatment activity provided to a Medicaid-eligible beneficiary who
				is experiencing a psychiatric or behavioral crisis. Services are to be
				congruent with the age, strengths, needed accommodation for any disability, and
				cultural framework of the beneficiary and their family. These services, which
				can include interventions, stabilization activities, evaluation, coping
				strategies, and other various activities to assist the beneficiary in crisis,
				are designed to stabilize the person in crisis, prevent further deterioration,
				and provide immediate indicated treatment in the least restrictive setting. The
				services provided are expected to reduce or eliminate the risk of harm to the
				person or others in order to stabilize the beneficiary.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician
xxxii. Substance Abuse Detoxification*
Definition: Substance Abuse Detoxification is a set of
				interventions aimed at managing acute intoxication and withdrawal from alcohol
				or other drugs. Services help stabilize beneficiaries by clearing toxins from
				the beneficiary's body. Services are short-term, may be provided in a crisis
				unit, residential, or outpatient setting, and may include evaluation,
				observation, medical monitoring, and addiction treatment.
Detoxification seeks to minimize the physical harm caused by
				the abuse of substances and prepares the beneficiary for ongoing
				treatment.
This service will not be paid for within an Institution for
				Mental Disease (IMD).
This service does not include payment for room and board of the
				beneficiary.
Substance Abuse Detoxification Unit must be certified
				by the Department of Human Services as a Substance Abuse Detoxification
				provider.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral
				Health Provider - Non-Degreed.
Six encounters are allowed per State Fiscal Year (July
				1 through June 30). Extension of Benefits for Medically Necessary Encounters
				beyond the first six (6) is required.
*All medically necessary 1905(a) services, that correct or
				ameliorate physical and mental illnesses and conditions, are covered for EPSDT
				eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of
				the Social Security Act.
ATTACHMENT 3.1-B
13. Other diagnostic, screening, preventive, and rehabilitative
				services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
3. Outpatient Behavioral Health Services (OBHS)
xxix. Crisis Care - De-escalation*
Eligibility for this service is determined by an Independent
				Assessment and must be prior authorized.
DEFINITION: Crisis Care - De-escalation provides temporary
				direct care for a beneficiary in the beneficiary's community that is not
				facility-based. Crisis Care - De-escalation services de-escalate stressful
				situations and provide a therapeutic outlet. Crisis Care includes behavioral
				interventions that keep beneficiaries in their current situation and reduces
				the need for acute hospitalization or other higher levels of care. Crisis Care
				shall be indicated in the treatment plan.
This service will not be paid for within an Institution for
				Mental Disease (IMD)
.
This service does not include payment for room and board of the
				beneficiary.
Crisis Care - De-escalation provider must be certified
				by the Department of Human Services as a Crisis Care - De-escalation
				provider.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral
				Health Provider - Non-Degreed.
xxx. Acute Crisis Units*
Definition: Acute Crisis Units provide brief, 96 hours or less,
				crisis treatment services to persons over the age of 17 who are experiencing a
				psychiatry- and/or substance abuse-related crisis and may pose an escalated
				risk of harm to self or others. Acute Crisis Units provide hospital diversion
				and step-down services in a safe environment with psychiatry and/or substance
				abuse services on-site at all times as well as on-call psychiatry available 24
				hours a day. Services provide ongoing assessment and observation; crisis
				intervention; psychiatric, substance, and co-occurring treatment; and initiate
				referral mechanisms for independent assessment and care planning as
				needed.
This service will not be paid for within an Institution for
				Mental Disease (IMD).
This service does not include payment for room and board of the
				beneficiary.
Acute Crisis Unit must be certified by Department of
				Human Services as an Acute Crisis Unit.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral
				Health Provider - Non-Degreed.
An Extension of Benefit for medical necessity is
				required for admissions exceeding ninety-six (96) hours.
*All medically necessary 1905(a) services that correct or
				ameliorate physical and mental illnesses and conditions are covered for EPSDT
				eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of
				the Social Security Act.
13. Other diagnostic, screening, preventive, and rehabilitative
				services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
3. Outpatient Behavioral Health Services (OBHS)
xxxi. Crisis Intervention*
DEFINITION: Crisis Intervention is an unscheduled, immediate,
				short-term treatment activity provided to a Medicaid-eligible beneficiary who
				is experiencing a psychiatric or behavioral crisis. Services are to be
				congruent with the age, strengths, needed accommodation for any disability, and
				cultural framework of the beneficiary and his/her family. These services, which
				can include interventions, stabilization activities, evaluation, coping
				strategies and other various activities to assist the beneficiary in crisis,
				are designed to stabilize the person in crisis, prevent further deterioration,
				and provide immediate indicated treatment in the least restrictive setting. The
				services provided are expected to reduce or eliminate the risk of harm to the
				person or others, in order to stabilize the beneficiary.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician
xxxii. Substance Abuse Detoxification*
Definition: Substance Abuse Detoxification is a set of
				interventions aimed at managing acute intoxication and withdrawal from alcohol
				or other drugs. Services help stabilize beneficiaries by clearing toxins from
				the beneficiary's body. Services are short-term and may be provided in a crisis
				unit, residential, or outpatient setting, and may include evaluation,
				observation, medical monitoring, and addiction treatment. Detoxification seeks
				to minimize the physical harm caused by the abuse of substances and prepares
				the beneficiary for ongoing treatment.
Substance Abuse Detoxification Unit must be certified
				by the Department of Human Services as a Substance Abuse Detoxification
				provider.
This service will not be paid for within an Institution for
				Mental Disease (IMD).
This service does not include payment for room and board of the
				beneficiary.
Allowable Performing Provider - Independently Licensed
				Clinician - Master's/Doctoral; Non-Independently Licensed Clinician -
				Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse;
				Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral
				Health Provider - Non-Degreed.
Six (6) encounters are allowed per State Fiscal Year
				(July 1 through June 30). Extension of Benefits for Medically Necessary
				Encounters beyond the first six (6) is required.
*All medically necessary 1905(a) services that correct or
				ameliorate physical and mental illnesses and conditions are covered for EPSDT
				eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of
				the Social Security Act.