Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-033 - Rehabilitative Services for Persons with Mental Illness Update #114

Current through Register Vol. 49, No. 6, June, 2024
Section II
Rehabilitative Services for Persons with Mental Illness
201.000
Introduction
Medicaid (Medical Assistance) is designed to assist eligible
				Medicaid beneficiaries in obtaining medical care within the guidelines
				specified in Section
				I of this manual. Rehabilitative
				Services for Persons with Mental Illness (RSPMI) are covered by Medicaid when
				provided to eligible Medicaid beneficiaries by enrolled providers.
RSPMI may be provided to eligible Medicaid beneficiaries at all
				provider facility certified sites. Acceptable allowable places of service are
				found in the service definitions located in section
				252.110.
219.140
Telemedicine (Interactive
			 Electronic Transactions) RSPMI Services
RSPMI telemedicine services are interactive electronic
				transactions performed "face-to-face" in real time, via two-way electronic
				video and audio data exchange.
The mental health professional may provide certain treatment
				services from a remote site to the Medicaid-eligible beneficiary age 21 or over
				who is located in a mental health clinic setting. There must be an employee of
				the clinic in the same room with the beneficiary. Refer to Section
				252.140 for billing
				instructions.
The following services may be provided via telemedicine by a
				mental health professional:
A. Mental
			 Health Evaluation/Diagnosis,
B.
			 Interpretation of Diagnosis,
C.
			 Individual Psychotherapy,
D.
			 Marital/Family Psychotherapy - Beneficiary is not present,
E. Marital/Family Psychotherapy - Beneficiary
			 is present,
F. Psychiatric
			 Diagnostic Assessment,
G. Crisis
			 Intervention,
H. Crisis
			 Stabilization Intervention, Mental Health Professional,
I. Pharmacologic Management by
			 Physician,
J. Collateral
			 Intervention, Mental Health Professional; and
K. Intervention, Mental Health Professional.
219.141
Services
			 Available to Residents of Long Term Care Facilities
The following RSPMI services may be provided to residents of
				nursing homes and ICF/MR facilities who are Medicaid eligible when the services
				are prescribed according to policy guidelines detailed in this manual:
A. Mental Health
			 Evaluation/Diagnosis,
B.
			 Psychological Evaluation,
C.
			 Pharmacologic Management by Physician,
D. Master Treatment Plan,
E. Periodic Review of Master Treatment
			 Plan,
F. Interpretation of
			 Diagnosis,
G. Individual
			 Psychotherapy,
H. Crisis
			 Intervention.
Services provided to nursing home and ICF/MR residents may be
				provided on- or off-site from the RSPMI provider if allowable per the service
				definition. Some services may be provided in the long-term care (LTC) facility,
				if necessary.
228.200
Medicaid Program Integrity Unit
These tasks have been mandated by federal regulations. The
				Medicaid Program Integrity Unit shall:
A. Conduct on-site medical audits for the
			 purpose of verifying the nature and extent of service paid for by the Medicaid
			 Program;
B. Research all inquiries
			 from beneficiaries in response to the Explanation of Medicaid Benefits;
			 and
C. Retrospectively evaluate
			 medical practice patterns and providers' patterns by comparing each provider's
			 pattern to norms and limits set by all the providers of the same specialty.
231.100
Prior
			 Authorization and Extension of Benefits
Prior Authorization is required for certain services provided
				to Medicaid-eligible individuals. Extension of benefits is required for all
				other services when the maximum benefit for the service is exhausted. Yearly
				service benefits are based on the state fiscal year running from July 1 to June
				30. Extension of Benefits is also required whenever a beneficiary exceeds eight
				hours of outpatient services in one 24-hour day, with the exception of crisis
				intervention, crisis stabilization intervention by a mental health
				professional, and crisis stabilization intervention by paraprofessional.
Prior authorization and extension requests must be sent to APS
				Healthcare for beneficiaries under the age of 21. View or print APS Healthcare
				contact information. Information related to clinical management guidelines and
				authorization request processes is available at
www.apshealthcare.com.
Prior authorization and extension requests must be sent to
				First Health for beneficiaries age 21 and over. View or print First Health
				contact information. Information related to clinical management guidelines and
				authorization request processes is available at
https://arkansas.fhsc.com/
Procedure codes requiring prior authorization:
National Codes
Required Modifier
Service Title
90846
HA, U3,
Marital/Family Therapy without
90846
-
patient present
90846
U7 (telemedicine )
90853
HA, U1
Group Outpatient - Group
90853
-
Psychotherapy
90862
HA, HQ
Group Outpatient -
Pharmacologic Management by Physician
H2012
HA
Therapeutic Day/Acute Day
H2012
UA
Treatment
90887
HA
Collateral Intervention, MHP
90887
U7 (telemedicine)
90887
HA, UB
Collateral Intervention, MHPP
H2015
HA, U5
Intervention, MHP
H2015
U6
H2015
U7 (telemedicine)
H2015
HA, U1
Intervention, MHPP
H2015
U2
H2017
HA, U1
Rehabilitative Day Service
H2017
-
Procedure codes requiring Extension of Benefits:
National Codes
Required Modifier
Service Title
Yearly Maximum
90801
HA, U1
Mental Health
16
90801
U7 (telemedicine)
Evaluation/Diagnosis
96101
HA, UA
Psychological Evaluation
32
90885
HA, U2
Master Treatment Plan
8
90887
HA, U2
Interpretation of Diagnosis
16
90887
U3, U7 (telemedicine)
H0004
Individual Psychotherapy
48
H0004
HA
H0004
U7 (telemedicine)
90847
HA, U3
Marital/Family Therapy
48
90847
-
with patient present
90847
U7 (telemedicine)
H2011
HA
Crisis Intervention
72
H2011
U7 (telemedicine)
T1023
HA, U1
Psychiatric Diagnostic
1
T1023
U7 (telemedicine)
Assessment (Note that code T1023-HA,U1 was formerly
						  applied to Assessment and Treatment Plan/Plan of Care)
99201
HA, UB
Physical Examination
12
99202
HA, UB
99203
HA, UB
99204
HA, UB
99212
HA, UB
99213
HA, UB
99214
HA, UB
AND
99201
HA, SA
99202
HA, SA
99203
HA, SA
99204
HA, SA
99212
HA, SA
99213
HA, SA
99214
HA, SA
90862
HA
Pharmacologic
24
90862
-
Management
90862
HA, UB
90862
U7 (telemedicine)
90885
HA
Periodic Review of Master
10
90885
HA, U1
treatment plan
36415
HA
Routine Venipuncture for
12
Collection of Specimen
H2011
HA, U6
Crisis Stabilization, MHP
72
H2011
U2
H2011
U2, U7 (telemedicine)
H2011
HA, U5
Crisis Stabilization,
72
H2011
U1
MHPP
252.110
Outpatient Procedure
			 Codes
National Code
Required Modifier
Definition
92506
HA
Diagnosis: Speech
						  Evaluation
1 unit = 30 minutes
Maximum units per day: 4
Maximum units per state fiscal year (SFY) = 4
						  units
90801
HA, U1
SERVICE
:
Mental Health
						  Evaluation/Diagnosis (Formerly known only as Diagnosis
)
DEFINITION:
The cultural, developmental,
						  age and disability -
relevant clinical evaluation and determination of a
						  beneficiary's mental status; functioning in various life domains; and an axis
						  five
DSM diagnostic formulation for the purpose of
						  developing a plan of care. This service is required prior to provision of all
						  other mental health services with the exception of crisis interventions.
						  Services are to be congruent with the age, strengths, necessary,
accommodations for disability, and cultural framework
						  of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
8,
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED
						  without
extension:
16
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); Nursing Facility (32); Skilled Nursing
						  Facility (31);
School (03); Homeless Shelter (04); Assisted Living
						  Facility (13);
Group Home (14); ICF/MR (54)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
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 and strengths in
						  specified life domains
.
DSM diagnostic impressions to include
						  all five axes
.
Treatment recommendations
.
Staff signature/credentials/date of
						  signature
NOTES and COMMENTS:
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. Prior Authorization requests, master treatment plans, etc.).
90801
U7
Mental Health Evaluation/Diagnosis;
Use
						  the above definition and requirements.
Additional information: Use code 90801 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
96101
HA, UA
SERVICE: Psychological Evaluation (Formerly
						  Diagnosis -Psychological Test/Evaluation and Diagnosis - Psychological Testing
						  Battery)
DEFINITION:
A Psychological Evaluation
						  employs standardized psychological tests conducted and documented for
						  evaluation, diagnostic, or therapeutic purposes. The evaluation must be
						  medically necessary, culturally relevant; with reasonable accommodations for
						  any disability, provide information relevant to the beneficiary's continuation
						  in treatment, and assist in treatment planning. All psychometric instruments
						  must be administered, scored, and interpreted by the qualified professional.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
16
YEARLY MAXIMUM
						  OF UNITS THAT MAY BE BILLED without extension
: 32
ALLOWABLE PLACES OF SERVICE:
Office (11)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Start and stop times of actual encounter
						  with beneficiary
.
Start and stop times of scoring,
						  interpretation and report preparation
.
Place of service
.
Identifying information
.
Rationale for referral
.
Presenting problem(s)
.
Culturally- and age-appropriate
						  psychosocial history and assessment
.
Mental status/Clinical observations and
						  impressions
.
Psychological tests used, results, and
						  interpretations, as indicated
.
Axis Five DSM diagnostic
						  impressions
.
Treatment recommendations and findings
						  related to rationale for service and guided by the master treatment plan and
						  test results
.
Staff signature/credentials/date of
						  signature(s)
NOTES and COMMENTS:
Medical necessity for this
						  service is met when the service is necessary to establish a differential
						  diagnosis of behavioral or psychiatric conditions, when the history and
						  symptomatology are not readily attributable to a particular
psychiatric diagnosis and the questions to be answered
						  by the evaluation could not be resolved by a psychiatric/diagnostic interview,
						  observation in therapy, or an assessment for level of care at a mental health
						  facility,
Or
Medical necessity is met when the beneficiary has
						  demonstrated a complexity of issues related to cognitive functioning or the
						  impact of a disability on a condition or behavior and the service is necessary
						  to develop treatment recommendations after the beneficiary has received various
						  treatment services and modalities, has not progressed in treatment, and
						  continues to be symptomatic. Medicaid WILL NOT reimburse evaluations or testing
						  that is considered primarily educational. Such services are those used to
						  identify specific learning disabilities and developmental disabilities in
						  beneficiaries who have no presenting behavioral or psychiatric symptoms which
						  meet the need for mental health treatment evaluation. This type of evaluation
						  and testing is provided by local school systems under applicable state and
						  federal laws and rules. Psychological Evaluation services that are ordered
						  strictly as a result of court-ordered services are not covered unless medical
						  necessity criteria are met. Psychological Evaluation services for employment,
						  disability qualification, or legal/court related purposes are not reimbursable
						  by Medicaid as they are not considered treatment of illness. A Psychological
						  Evaluation report must be completed within fourteen (14) calendar days of the
						  examination; documented; clearly identified as such; and signed/dated by the
						  staff completing the evaluation. This service constitutes both face to face
						  time administering tests to the beneficiary and time interpreting these test
						  results and preparing the report.
T1023
HA, U1
SERVICE: Psychiatric Diagnostic Assessment (Note
						  that code T1023-HA,U1 was formerly applied to Assessment and Treatment
						  Plan/Plan of Care)
DEFINITION:
A direct face-to-face service
						  contact occurring between the physician and the beneficiary for the purpose of
						  evaluation. Psychiatric Diagnostic Assessment includes a history,
mental status, and a disposition, and may include
						  communication with family or other sources, ordering and medical interpretation
						  of laboratory or other medical diagnostic studies. (See Section
224.000 for requirements.)
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
This service must be billed as 1 per episode.
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED:
1
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); School (03); Homeless Shelter (04); Assisted
						  Living
Facility (13); Group Home (14)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS:
Date of Service Start and stop times Place of
						  service
Diagnosis
Diagnostic Impression
Psychiatric (re)assessment
Functional (re)assessment
Discharge criteria
Physician's signature indicating medical
						  necessity/credentials/date of signature
NOTES and COMMENTS:
The beneficiary must
						  be reassessed,
reviewed, and recertified at least every year.
T1023
U7
SERVICE: Psychiatric Diagnostic Assessment (Note
						  that code T1023-HA,U1 was formerly applied to Assessment and Treatment
						  Plan/Plan of Care):
Use the above definition and requirements. Additional
						  Information: Use code T1023 with modifier "U7" to claim for services provided
						  via telemedicine only. Note: Telemedicine POS 99
90885
HA, U2
SERVICE: Master Treatment Plan
DEFINITION:
A developed plan in
						  cooperation with the beneficiary
(parent or guardian if the beneficiary is under 18), to
						  deliver specific mental health services to the beneficiary to restore,
improve or stabilize the beneficiary's mental health
						  condition. The plan must be based on individualized service needs identified in
						  the completed Mental Health Diagnostic Evaluation. The plan must include goals
						  for the medically necessary treatment of identified problems, symptoms and
						  mental health conditions. The plan must identify individuals or treatment teams
						  responsible for treatment,
specific treatment modalities prescribed for the
						  beneficiary, time limitations for services, and documentation of medical
						  necessity by the supervising physician
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED
						  without
extension:
8
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); Nursing Facility (32); Skilled Nursing
						  Facility (31);
School (03); Homeless Shelter (04); Assisted Living
						  Facility (13);
Group Home (14); ICF/MR (54);
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
Date of Service (date plan is
						  developed)
.
Start and stop times for development of
						  plan
.
Place of service
.
Diagnosis
.
Beneficiary's strengths and needs
.
Treatment goal(s) developed in
						  cooperation with and as stated by beneficiary that are related specifically to
						  the beneficiary's strengths and needs
.
Measurable objectives
.
Treatment modalities - The specific
						  services that will be
used to meet the measurable objectives
.
Projected schedule for service delivery, including amount,
scope, and duration
.
Credentials of staff
						  who will be providing the services
.
Discharge criteria
.
Signature/credentials of staff drafting the document and primary staff
						  who will be delivering or supervising the delivery of the specific services/
						  date of signature(s)
.
Beneficiary's signature (or signature of
						  parent, guardian, or custodian of beneficiaries under the age of 18)/ date of
						  signature
.
Physician's signature indicating medical necessity
						  /date of signature
NOTES and COMMENTS:
The service formerly
						  coded as T1023 and titled "Assessment and Treatment Plan/Plan of Care" is now
						  incorporated into this service. This service may be billed one (1) time upon
						  entering care and once yearly thereafter. The master treatment plan must be
						  reviewed every ninety (90) calendar days or more frequently if there is
						  documentation of significant acuity changes in clinical status requiring an
						  update/change in the beneficiary's master treatment plan. It is the
						  responsibility of the primary mental health professional to insure that all
						  paraprofessionals working with the client have a clear understanding and work
						  toward the goals and objectives stated on the treatment plan.
90885
HA
SERVICE: Periodic Review of Master Treatment
						  Plan
DEFINITION:
The periodic review and
						  revision of the master treatment plan, in cooperation with the beneficiary, to
						  determine the beneficiary's progress or lack of progress toward the master
						  treatment plan goals and objectives; the efficacy of the services provided; and
						  continued medical necessity of services. This includes a review and revision of
						  the measurable goals and measurable objectives directed at the medically
						  necessary treatment of identified symptoms/mental health condition, individuals
						  or treatment teams responsible for treatment, specific treatment modalities,
						  and necessary accommodations that will be provided to the beneficiary, time
						  limitations for services, and the medical necessity of continued services.
						  Services are to be congruent with the age, strengths, necessary accommodations
						  for any disability, and cultural framework of the beneficiary and his/her
						  family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
2
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without extension:
10
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
						  School (03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
						  (14); ICF/MR (54)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
Completed by the primary MHP (If not, then must
						  have a rationale for another MHP completing the documentation and only with
						  input from the primary MHP)
.
Date of service
.
Start and stop times for review and
						  revision of plan
.
Place of service
.
Diagnosis and pertinent interval
						  history
.
Beneficiary's updated strengths and
						  needs
.
Progress/Regression with regard to
						  treatment goal(s) as documented in the master.
.
Progress/Regression of the measurable objectives as documented in the master
						  treatment plan
.
Individualized rationale to support the medical
						  necessity of continued services
.
Updated schedule for service
						  delivery, including amount,
scope, and duration
.
Credentials of staff
						  who will be providing the services
.
Modifications to discharge
						  criteria
.
Signature/credentials of staff drafting the document
						  and primary staff who will be delivering or supervising the delivery of the
						  specific services/date of signature(s)
.
Beneficiary's signature
						  (or signature of parent, guardian, or custodian of beneficiaries under the age
						  of 18)/date of signature(s)
.
Physician's signature indicating
						  continued medical necessity/date of signature
NOTES and COMMENTS:
This service must be provided every ninety (90) days or more frequently if
						  there is documentation of significant change in acuity or change in clinical
						  status requiring an update/change in the beneficiary's master treatment plan.
						  If progress is not documented, then modifications should be made in the master
						  treatment plan or rationale why continuing to provide the same type and amount
						  of services is expected to achieve progress/outcome. It is the responsibility
						  of the primary mental health professional to insure that all paraprofessionals
						  working with the client have a clear understanding and work toward the goals
						  and objectives stated on the treatment plan.
90885
HA, U1
Periodic Review of Master Treatment Plan
Apply the above description.
Additional information: Use code 90885 with modifier
						  "U1" to claim for this service when provided by a non-physician.
90887
HA, U2
SERVICE: Interpretation of
						  Diagnosis
DEFINITION:
A face-to face therapeutic
						  intervention provided to a beneficiary in which the
						  results/implications/diagnoses from a mental health diagnosis evaluation or a
						  psychological evaluation are explained by the professional who administered the
						  evaluation. Services are to be congruent with the age, strengths,
						  necessary
accommodations, and cultural framework of the
						  beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED
						  without
extension:
16
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); Nursing Facility (32); Skilled Nursing
						  Facility (31);
School (03); Homeless Shelter (04); Assisted Living
						  Facility (13);
Group Home (14); ICF/MR (54)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
Start and stop times of face to face
						  encounter with beneficiary and/or parents or guardian
.
Date of service
.
Place of service
.
Participants present and relationship to
						  beneficiary
.
Diagnosis
.
Rationale for and intervention used that
						  must coincide with the master treatment plan or proposed master treatment plan
						  or recommendations.
.
Participant response and feedback
.
Any changes or revision to the master
						  treatment plan, diagnosis, or medication(s)
.
Staff signature/credentials/date of
						  signature(s)
NOTES AND COMMENTS:
For beneficiaries
						  under the age of 18, 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 the age of 18, the time may be spent
						  face-to-face with the beneficiary and the spouse, legal guardian or significant
						  other.
90887
U3, U7
Interpretation of Diagnosis
Use above definition and requirements
Additional information: Use code 90887 with modifier
						  "U3, U7" to claim for services provided via telemedicine only. Note:
						  Telemedicine POS 99
H0004
HA
SERVICE: Individual Psychotherapy
DEFINITION
Face-to-face treatment provided
						  by a licensed mental health professional on an individual basis. Services
						  consist of structured sessions that work toward achieving mutually defined
						  goals as documented in the master treatment plan. Services are to be congruent
						  with the age, strengths, needed accommodations necessary for any disability,
						  and cultural framework of the beneficiary and his/her family. The treatment
						  service must reduce or alleviate identified symptoms, maintain or improve level
						  of functioning, or prevent deterioration.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension:
48
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); Nursing Facility (32); Skilled Nursing
						  Facility (31)
School (03); Homeless Shelter (04); Assisted Living
						  Facility (13);
Group Home (14); ICF/MR (54)
AGE GROUP(S):
U21, but not for
						  beneficiaries under the age of 3
except in documented exceptional cases
REQUIRED DOCUMENTATION (See Section
						  226.200 for additional
						  requirements): .
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 intervention used that must coincide with the master
.
Beneficiary's response to intervention that includes current
						  progress or regression and prognosis
.
Any revisions indicated for
						  the master treatment plan,
diagnosis, or medication(s)
.
Plan for
						  next individual therapy session, including any homework assignments and/or
						  advanced psychiatric directive
.
Staff signature/credentials/date
						  of signature
NOTES and COMMENTS:
Services provided must
						  be congruent with the objectives and interventions articulated on the most
						  recent treatment plan. 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.
H0004
-
Individual Psychotherapy
Use above definition and requirements.
Additional information: Use code H0004 with no modifier
						  to claim for services provided to beneficiaries ages 21 and over.
H0004
U7
Individual Psychotherapy
Use above definition and requirements.
Additional information: Use code H0004 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
90846
HA, U3
SERVICE: Marital/Family Psychotherapy -
						  Beneficiary is not present
DEFINITION:
Face-to-face treatment
						  provided to more than one member of a family simultaneously in the same session
						  or treatment with an individual family member (i.e. Spouse or Single Parent)
						  that is specifically related to achieving goals identified on
the beneficiary's master treatment plan. The identified
						  beneficiary is not present for this service. Services are to be congruent with
						  the age, strengths, needed accommodations for any disability, and cultural
						  framework of the beneficiary and his/her family. These services identify and
						  address marital/family dynamics and improve/strengthen marital/family
						  interactions and functioning in relationship to the beneficiary, the
						  beneficiary's condition and the condition's impact on the marital/family
						  relationship.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
6
REQUIRES PRIOR AUTHORIZATION
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements): .
Date of Service
.
Start and stop times of actual encounter
						  with spouse/family
.
Place of service
.
Participants
						  present
.
Nature of relationship with beneficiary
.
Rationale for excluding the identified beneficiary
.
Diagnosis
						  and pertinent interval history
.
Rationale for and intervention
						  used that must coincide with the master treatment plan and improve the impact
						  the beneficiary's condition has on the spouse/family and/or improve
						  marital/family interactions between the beneficiary and the spouse/family.
.
Spouse/Family response to intervention that includes current
						  progress or regression and prognosis
.
Any changes indicated for
						  the master treatment plan,
diagnosis, or medication(s)
.
Plan for
						  next session, including any homework assignments and/or crisis plans
.
HIPPA compliant Release of information forms, completed,
signed and dated
.
Staff
						  signature/credentials/date of signature
NOTES and COMMENTS:
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 beneficiary per family per therapy session may be billed.
90846
-
Marital/Family Psychotherapy - Beneficiary is not
						  present
Use the above definition and requirements.
Additional information: Use code 90846 with no modifier
						  to claim for services provided to beneficiaries ages 21 and over.
90846
U7
Marital/Family Psychotherapy
-
Beneficiary is not present
Use the above definition and requirements.
Additional information: Use code 90846 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
90847
HA, U3
SERVICE: Marital/Family Psychotherapy -
						  Beneficiary is present
DEFINITION:
Face-to-face treatment
						  provided to more than one member of a family simultaneously in the same session
						  or treatment with an individual family member (i.e. Spouse or Single Parent)
						  that is specifically related to achieving goals identified on the beneficiary's
						  master treatment plan. The identified beneficiary must be present for this
						  service. Services are to be congruent with the age, strengths, needed
						  accommodations for disability, and cultural framework of the beneficiary and
						  his/her family. These services are to be utilized to identify and address
						  marital/family dynamics and improve/strengthen marital/family interactions and
						  functioning in relationship to the beneficiary, the beneficiary's condition and
						  the condition's impact on the marital/family relationship.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
6
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without extension:
48
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements): .
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 for, and description of intervention
						  used that must coincide with the master treatment plan and improve the impact
						  the beneficiary's condition has on the spouse/family and/or improve
						  marital/family interactions between the beneficiary and the spouse/family.
.
Beneficiary and spouse/family's response to intervention that
						  includes current progress or regression and prognosis
.
Any
						  changes indicated for the master treatment plan,
diagnosis, or medication(s)
.
Plan for
						  next session, including any homework assignments and/or crisis plans
.
Staff signature/credentials/date of signature
.
HIPAA compliant release of Information,
						  completed, signed and dated
NOTES and COMMENTS:
Natural supports
						  may be included in these sessions if justified in service documentation and if
						  supported in the master treatment plan. Only one beneficiary per family per
						  therapy session may be billed.
Additional information: Use code 90847 with modifiers
						  "HA, U3" to claim for services provided to beneficiaries under age 21.
90847
-
Marital/Family Psychotherapy - Beneficiary is
						  present
Use the above definition and requirements.
Additional information: Use code 90847 with no modifier
						  to claim for services provided to beneficiaries ages 21 and over.
90847
U7
Marital/Family Psychotherapy - Beneficiary is
						  present
Use the above definition and requirements.
Additional information: Use code 90847 with modifier
						  "U7" to claim for services provided via telemedicine only. Telemedicine POS
						  99
92507
HA
Individual Outpatient - Speech Therapy, Speech
						  Language Pathologist
Scheduled individual outpatient care provided by a
						  licensed speech pathologist supervised by a physician to a Medicaid-eligible
						  beneficiary for the purpose of treatment and remediation of a communicative
						  disorder deemed medically necessary. See the Occupational, Physical and Speech
						  Therapy Program Provider Manual for specifics of the speech therapy
						  services.
92507
HA, UB
Individual Outpatient - Speech Therapy, Speech
						  Language Pathologist Assistant
Scheduled individual outpatient care provided by a
						  licensed speech pathologist assistant supervised by a qualified speech language
						  pathologist to a Medicaid-eligible beneficiary for the purpose of treatment and
						  remediation of a communicative disorder deemed medically necessary. See the
						  Occupational, Physical and Speech Therapy Program Provider Manual for specifics
						  of the speech therapy services.
92508
HA
Group Outpatient - Speech Therapy, Speech
						  Language Pathologist
Contact between a group of Medicaid-eligible
						  beneficiaries and a speech pathologist for the purpose of speech therapy and
						  remediation. See the Occupational, Physical and Speech Therapy Provider Manual
						  for specifics of the speech therapy services.
92508
HA, UB
Group Outpatient - Speech Therapy, Speech
						  Language Pathologist Assistant
Contact between a group of Medicaid-eligible
						  beneficiaries and a speech pathologist assistant for the purpose of speech
						  therapy and
remediation. See the Occupational, Physical and Speech
						  Therapy Provider Manual for specifics of the speech therapy services.
90853
HA, U1
SERVICE: Group Outpatient - Group
						  Psychotherapy
DEFINITION:
Face-to-face interventions
						  provided to a group of beneficiaries on a regularly scheduled basis to improve
						  behavioral or cognitive problems which either cause or exacerbate mental
						  illness. The professional uses the emotional interactions of the group's
						  members to assist them in implementing each beneficiary's master treatment
						  plan. Services are to be congruent with the age,
strengths, needed accommodation for any disability, and
						  cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
6
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  School (03);
Homeless Shelter (04); Assisted Living Facility (13);
						  Group Home
(14);
AGE GROUP(S):
Ages 4 - 20; Under age 4 by
						  prior authorized medically needy exception
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements): .
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 intervention and intervention used that must
						  coincide with master treatment plan
.
Beneficiary's response to
						  the group intervention that includes current progress or regression and
						  prognosis
.
Any changes indicated for the master treatment
						  plan,
diagnosis, or medication(s)
.
Plan for
						  next group session, including any homework assignments
.
Staff
						  signature/credentials/date of signature
NOTES and COMMENTS:
This does NOT include
psychosocial groups.
Beneficiaries eligible for Group
						  Outpatient - Group Psychotherapy 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 aged 18 and over, the minimum number that must be served in a
						  specified group is 2. The maximum that may be served in a specified group is
						  12. For groups of beneficiaries under 18 years of age, the minimum number that
						  must be served in a specified group is 2. The maximum that may be served in a
						  specified group is 10. A beneficiary must be 4 years of age to receive group
						  therapy. Group
treatment must be age and developmentally appropriate,
						  (i.e.: 16 year olds and 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,
90853
-
Group Outpatient - Group Psychotherapy
Apply the above definition and requirements.
Additional information: Use code 90853 with no modifier
						  to claim for services provided to beneficiaries ages 21 and over.
H2012
HA
SERVICE: Therapeutic Day/Acute Day
						  Treatment
DEFINITION:
Short-term daily array of
						  continuous, highly structured, intensive outpatient services provided by a
						  mental health professional. These services are for beneficiaries experiencing
						  acute psychiatric symptoms that may result in the beneficiary being in imminent
						  danger of psychiatric hospitalization and are designed to stabilize the acute
						  symptoms. These direct therapy and medical services are intended to be an
						  alternative to inpatient psychiatric care and are expected to reasonably
						  improve or maintain the beneficiary's condition and functional level to prevent
						  hospitalization and assist with assimilation to his/her community after an
						  inpatient psychiatric stay of any length. These services are to be provided by
						  a team consisting of mental health clinicians, paraprofessionals and nurses,
						  with physician oversight and availability. The team composition may vary
						  depending on clinical and programmatic needs but must at a minimum include a
						  licensed mental health clinician and physician who provide services and
						  oversight. 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 must include constant staff supervision of
						  beneficiaries and physician oversight.
DAILY MAXIMUM OF UNITS THAT MAY BE
						  BILLED:
32
PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF
						  SERVICE:
Office (11)
STAFF to CLIENT RATIO:
1:5 for ages 18
						  and over; 1:4 for U18
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Start and stop times of actual program
						  participation by beneficiary
.
Place of service
.
Diagnosis and pertinent interval
						  history
.
Brief mental status and
						  observations
.
Rationale for and interventions used
						  that must coincide with the master treatment plan
.
Beneficiary's response to the
						  intervention must include current progress or lack of progress toward symptom
						  reduction and attainment of goals
.
Rationale for continued acute day
						  service, including
necessary changes to diagnosis, master treatment plan
						  or medication(s) and plans to transition to less restrictive services
.
Staff signature/credentials
NOTES and COMMENTS:
Providers
						  may bill for services only at times during which beneficiaries participate in
						  program activities. Providers are expected to sign beneficiaries in and out of
						  the program to provide medically necessary treatment therapies. However, in
						  order to be claimed separately, these therapies must be identified on the
						  Master Treatment Plan and serve a treatment purpose which cannot be
						  accomplished within the day treatment setting.
See Section
						  219.110 for additional
						  information.
H2012
UA
Therapeutic Day/Acute Day Treatment
Apply the above definition and requirements.
Additional Information: Use code H2012 with modifier
						  "UA" to claim for services provided to beneficiaries ages 21 and over.
See Section
						  219.110 for additional
						  information.
H2011
HA
SERVICE: Crisis Intervention
DEFINITION:
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, 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.)
DAILY MAXIMUM OF UNITS THAT MAY
						  BE BILLED:
12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
						  extension:
72
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
						  School (03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
						  (14); ICF/MR (54); Other Locations (99)
AGE GROUP(S):
Ages 21 and
						  over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Start and stop time of actual encounter
						  with beneficiary and possible collateral contacts with caregivers or informed
						  persons
.
Place of service (If 99 is used,
						  specific location and rationale for location must be included)
.
Specific persons providing pertinent
						  information in relationship to beneficiary
.
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 and COMMENTS:
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.
H2011
U7
Crisis Intervention
Apply the above definition and requirements.
Additional information: Use code H2011 plus modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
Physician
SERVICE: Physical Examination - Psychiatrist or
						  Physician
Physical Examination - Psychiatric Mental Health
						  Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse
						  Practitioner
:
HA, UB
99201
HA, UB
99202
HA, UB
99203
HA, UB
DEFINITION:
A general multisystem
						  examination based on age and risk factors to determine the state of health of
						  an enrolled RSPMI beneficiary.
99204
HA, UB
99212
HA, UB
99213
HA, UB
99214
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
PCNS & PANP:
extension:
12
ALLOWABLE PLACES OF SERVICE:
Office
						  (11)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
99201
HA, SA HA, SA
99202
HA, SA
additional requirements):
.
Start and stop times of actual encounter
						  with beneficiary
.
Date of service
.
Place of service
.
Identifying information
.
Referral reason and rationale for
						  examination
.
Presenting problem(s)
.
Health history
.
Physical examination
.
Laboratory and diagnostic procedures
						  ordered
.
Health education/counseling
99203
HA, SA
99204
HA, SA
99212
HA, SA
99213
HA, SA
99214
.
Identification of risk factors
.
Mental status/clinical observations and
						  impressions
.
ICD-9 diagnoses
.
DSM diagnostic impressions to include
						  all five axes
.
Any changes indicated for the master
						  treatment plan,
diagnosis, or medication(s)
.
Treatment
						  recommendations for findings, medications prescribed, and indicated informed
						  consents
.
Staff signature/credentials/date of signature(s)
NOTES and COMMENTS:
This service may be
						  billed only by the RSPMI provider. The physician, Psychiatric Mental Health
						  Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse
						  Practitioner may not bill for an office visit, nursing home visit, or any other
						  outpatient medical services procedure for the beneficiary for the same date of
						  service. Pharmacologic Management may not be billed on the same date of service
						  as Physical Examination, as pharmacologic management would be considered one
						  component of the full physical examination (office visit).
90862
HA
SERVICE: Pharmacologic Management by Physician
						  (formerly Medication Maintenance by a physician)
Pharmacologic Management by Mental Health
						  Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse
						  Practitioner
DEFINITION:
Provision of service tailored
						  to reduce, stabilize or eliminate psychiatric symptoms by addressing individual
						  goals in the master treatment plan. This service includes evaluation of the
						  medication prescription, administration, monitoring, and supervision and
						  informing beneficiaries regarding medication(s) and its potential effects and
						  side effects in order to make informed decisions regarding the prescribed
						  medications. Services must be congruent with the age, strengths, necessary
						  accommodations for any disability, and cultural framework of the beneficiary
						  and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
2
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without extension:
24
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14); Nursing Facility (32); Skilled Nursing Facility
						  (31); ICF/MR (54)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS(See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Start and stop times of actual encounter
						  with beneficiary
.
Place of service (If 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 intervention used that
						  must coincide with the master treatment plan
.
Beneficiary's
						  response to intervention that includes current progress or regression and
						  prognosis
.
Revisions indicated for the master treatment
						  plan,
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 24
						  hours of the prescription being written
.
Staff
						  signature/credentials/date of signature
NOTES and COMMENTS:
Applies only to medications prescribed to address targeted symptoms as
						  identified in the master treatment plan.
90862
-
Pharmacologic Management by Physician
Apply the above definition and requirements.
Additional information: Use code 90862 with no modifier
						  to claim for services provided to beneficiaries ages 21 and over.
90862
U7
Pharmacologic Management by Physician
Apply the above definition and requirements.
Additional information: Use code 90862 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
90862
HA, UB
Pharmacologic Management by Psychiatric Mental
						  Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse
						  Practitioner
Apply the above definition and requirements.
T1502
-
SERVICE: Medication Administration by a Licensed
						  Nurse
DEFINITION:
Administration of a
						  physician-prescribed medication to a beneficiary. This includes preparing the
						  beneficiary and medication; actual administration of oral, intramuscular and/or
						  subcutaneous medication; observation of the beneficiary after administration
						  and any possible adverse reactions; and returning the medication to its
						  previous storage.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED
1
ALLOWABLE PLACES OF SERVICE:
Office (11); Beneficiary's Home (12);
						  School (03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
						  (14); Other Locations (99)
AGE GROUP(S):
Ages 21 and over;
						  U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Time of the specific procedure
.
Place of service
.
Physician's order must be included in
						  medication log
.
Staff signature/credentials/date of signature
NOTES and COMMENTS: Applies only to medications prescribed to address
						  targeted symptoms as identified in the master treatment plan.
Drugs and
						  biologicals that can be self-administered shall not be in this group unless
						  there is a documented reason the patient cannot self administer.
						  Non-prescriptions and biologicals purchased by or dispensed to a patient are
						  not covered.
90862
HA, HQ
SERVICE: Group Outpatient - Pharmacologic
						  Management by a Physician
DEFINITION:
Therapeutic intervention
						  provided to a group of beneficiaries by a licensed physician involving
						  evaluation and maintenance of the Medicaid-eligible beneficiary on a medication
						  regimen with simultaneous supportive psychotherapy in a group setting. This
						  includes evaluating medication prescription, administration, monitoring, and
						  supervision; and informing beneficiaries regarding medication(s) and its
						  potential effects and side effects. Services are to be congruent with the age,
						  strengths, necessary accommodations for any disability, and cultural framework
						  of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE
						  BILLED:
6
PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF
						  SERVICE:
Office (11); Homeless Shelter (04); Assisted Living Facility
						  (13); Group Home (14)
AGE GROUP(S):
Ages 18 and over
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Start and stop times of actual group
						  encounter that includes identified beneficiary
.
Place of service
.
Number of participants
.
Diagnosis and pertinent interval
						  history
.
Focus of group
.
Brief mental status and
						  observations
.
Rationale for group intervention and
						  intervention used that must coincide with master treatment plan
.
Beneficiary's response to the group
						  intervention that includes current progress or regression and prognosis
.
Any changes indicated for the master
						  treatment plan, diagnosis, or medication(s)
.
If provided by physician that is not a
						  psychiatrist, then any off label uses of medications must include documented
						  consultation with the overseeing psychiatrist
.
Plan for next group session, including
						  any homework assignments
.
Staff signature/credentials/date of
						  signature(s)
NOTES and COMMENTS:
This service applies
						  only to medications prescribed to address targeted symptoms as
						  identified
in the master treatment plan. This does NOT include
psychosocial groups
in rehabilitative day programs or
						  educational groups. The maximum that may be served in a specified group is ten
						  (10). Providers may bill for services only at times during which beneficiaries
						  participate in this program activity.
36415
HA
SERVICE: Routine Venipuncture for Collection of
						  Specimen
DEFINITION:
The process of drawing a blood
						  sample through venipuncture (i.e., inserting a needle into a vein to draw the
						  specimen with a syringe or vacutainer) or collecting a urine sample by
						  catheterization as ordered by a physician or psychiatrist.
DAILY MAXIMUM
						  OF UNITS THAT MAY BE BILLED:
1, Per routine
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED
						  without
extension:
12
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Assisted
Living Facility (13); Other Locations (99)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
Date of Service
.
Time of the specific procedure
.
Place of service (If 99 is used,
						  specific location and rationale for location must be included)
.
Staff signature/credentials/date of
						  signature(s)
NOTES and COMMENTS:
This service may be provided only
						  to beneficiaries taking prescribed psychotropic medication or who have a
						  substance abuse diagnosis.
90887
HA
SERVICE: Collateral Intervention, Mental Health
						  Professional
DEFINITION:
A face-to-face contact by a
						  mental health professional with caregivers, family members, other
						  community-based service providers or other Participants on behalf of and with
						  the expressed written consent of an identified beneficiary in order to obtain
						  or share relevant information necessary to the enrolled beneficiary's
						  assessment, master treatment plan , and/or rehabilitation. The identified
						  beneficiary does not have to be present for this service. Services are to be
						  congruent with the age, strengths, needed accommodations for any disability,
						  and cultural framework of the beneficiary and his/her family.
DAILY
						  MAXIMUM OF UNITS THAT MAY BE BILLED:
4
PRIOR AUTHORIZATION
						  REQUIRED ALLOWABLE PLACES OF SERVICE:
Office (11); Patient's Home (12);
						  School (03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
						  (14); Other Locations (99)
AGE GROUP(S):
Ages 21 and over;
						  U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of Service
.
Names and relationship to the
						  beneficiary of all persons involved
.
Start and stop times of actual encounter
						  with collateral contact
.
Place of Service (If 99 is used,
						  specific location and rationale for location must be included)
.
Client diagnosis necessitating intervention
.
Document how
						  interventions used address goals and objectives from the master treatment plan
.
Information gained from collateral contact and how it relates
						  to master treatment plan objectives
.
Impact of information
						  received/given on the beneficiary's treatment
.
Any changes
						  indicated for the master treatment plan,
diagnosis, or medication(s)
.
Plan for
						  next contact, if any
.
Staff signature/credentials/Date of
						  signature
NOTES and COMMENTS:
The collateral intervention must be
						  identified on the master treatment plan as a medically necessary service.
						  Medicaid WILL NOT pay for incidental or happenstance meetings with individuals.
						  For example, a chance meeting with a beneficiary's adult daughter at the corner
						  store which results in a conversation regarding the well-being of the
						  beneficiary may not be billed as a collateral contact.
Billing for interventions performed by a mental health
						  professional must warrant the need for the higher level of staff licensure.
						  Professional interventions of a type which could be provided by a
						  paraprofessional will require documentation of the reason it was needed.
Contacts between individuals in the employment of RSPMI
						  agencies or facilities are not a billable collateral intervention.
90887
U7
Collateral Intervention, Mental Health
						  Professional
Apply the above definition and requirements.
Additional information: Use code 90887 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
90887
HA, UB
SERVICE: Collateral Intervention, Mental Health
						  Paraprofessional
DEFINITION:
A face-to-face contact by a
						  mental health paraprofessional with caregivers, family members, other
						  community-based service providers or other Participants on behalf of and with
						  the expressed written consent of an identified beneficiary in order to obtain
						  or share relevant information necessary to the enrolled beneficiary's
						  assessment, master treatment plan, and/or rehabilitation. Services are to be
						  congruent with the age, strengths, needed accommodation for any disability, and
						  cultural framework of the beneficiary and his/her family. The identified
						  beneficiary does not have to be present for this service.
DAILY MAXIMUM
						  OF UNITS THAT MAY BE BILLED:
4
PRIOR AUTHORIZATION
						  REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Patient's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14); Other Locations (99)
AGE GROUP(S):
Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements: .
Date of Service
.
Names and relationship to
						  the beneficiary of all persons involved
.
Start and stop times of
						  actual encounter with collateral contact
.
Place of Service (If 99
						  is used, specific location and rationale for location must be included)
.
Client diagnosis necessitating intervention
.
Document how interventions used address goals and objectives from the master
						  treatment plan
.
Information gained from collateral contact and
						  how it relates to master treatment plan objectives
.
Impact of
						  information received/given on the beneficiary's treatment
.
Any
						  changes indicated for the master treatment plan which must be documented and
						  communicated to the supervising MHP for consideration
.
Plan for
						  next contact, if any
.
Staff signature/credentials/Date of
						  signature
NOTES and COMMENTS
Supervision by a Mental Health
						  Professional must be documented in personnel files and addressed in accordance
						  of agency's policies, quality assurance procedures, personnel performance
						  evaluations, reports of supervisors, or other equivalent documented method of
						  supervision. The collateral intervention must be identified on the master
						  treatment plan as a medically necessary service. Medicaid WILL NOT pay for
						  incidental or happenstance meetings with individuals. For example, a chance
						  meeting with a beneficiary's adult daughter at the corner store which results
						  in a conversation regarding the well-being of the beneficiary may not be billed
						  as a collateral contact. Contacts between individuals in the employment of
						  RSPMI agencies or facilities are not a billable collateral intervention.
H2011
HA, U6
SERVICE: Crisis Stabilization Intervention,
						  Mental Health Professional
DEFINITION:
Scheduled face-to-face
						  treatment activities provided to a beneficiary who has recently experienced a
						  psychiatric or behavioral crisis that are expected to further stabilize,
						  prevent deterioration, and serve as an alternative to 24-hour inpatient care.
						  Services are to be congruent with the age, strengths, needed accommodation for
						  any disability, and cultural framework of the beneficiary and his/her
						  family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without extension:
72
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14); Other Locations (99)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements): .
Date of service
.
Start and stop time of actual encounter
						  with beneficiary
.
Place of service, (If 99 is used, specific
						  location and rationale for location must be included)
.
Diagnosis
						  and pertinent interval history
.
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 intervention that includes current progress or
						  regression and prognosis
.
Any changes indicated for the master
						  treatment plan,
diagnosis, or medication(s)
.
Plan for
						  next session, including any homework assignments
.
Staff
						  signature/credentials/date of signature(s)
NOTES and COMMENTS:
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.
H2011
U2
Crisis Stabilization Intervention, Mental Health
						  Professional
Apply the above definition and requirements.
Additional information: Use code H2011 with modifier
						  "U2" to claim for services provided to beneficiaries ages 21 and over.
H2011
U2, U7
Crisis Stabilization Intervention, Mental Health
						  Professional
Apply the above definition and requirements.
Additional information: Use code H2011 with modifier
						  "U2, U7" to claim for services provided via telemedicine only. Note:
						  Telemedicine POS 99
H2011
HA, U5
SERVICE: Crisis Stabilization Intervention,
						  Mental Health Paraprofessional
DEFINITION:
Scheduled face-to-face
						  treatment activities provided to a beneficiary who has recently experienced a
						  psychiatric or behavioral crisis that are expected to further stabilize,
						  prevent deterioration, and serve as an alternative to 24-hour inpatient care.
						  Services are to be congruent with the age, strengths, needed accommodation for
						  any disability, and cultural framework of the beneficiary and his/her
						  family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED
						  without
extension:
72
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's Home (12); School (03); Homeless Shelter (04); Assisted Living
						  Facility (13); Group Home (14); Other Locations (99)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements): .
Date of service
.
Start and stop time of actual encounter
						  with beneficiary
.
Place of service If 99 is used, specific
						  location and rationale for location must be included)
.
Diagnosis
						  and pertinent interval history
.
Behavioral observations
.
Consult with MHP or physician regarding
						  events that necessitated this service and the review of the outcome of the
						  intervention
.
Intervention used must coincide with the master
						  treatment plan, psychiatric advance directive or crisis plan which must be
						  documented and communicated to the supervising MHP
.
Beneficiary's
						  response to intervention that includes current progress or regression
.
Plan for next session, including any homework assignments
.
Staff signature/credentials/date of signature(s)
NOTES and
						  COMMENTS:
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. Supervision by a Mental Health Professional must be
						  documented and addressed in personnel files in accordance with the agency's
						  policies, quality assurance procedures, personnel performance evaluations,
						  reports of supervisors, or other equivalent documented method of
						  supervision.
H2011
U1
Crisis Stabilization Intervention, Mental Health
						  Paraprofessional
Apply the above definition and requirements.
Additional information: Use code H2011 with modifier
						  "U1" to claim for services provided to beneficiaries ages 21 and over
H2015
HA, U5
SERVICE: Intervention, Mental Health Professional
						  (formerly On-Site and Off-Site Interventions, MHP)
DEFINITION:
Face-to-face medically
						  necessary treatment activities provided to a beneficiary consisting of specific
						  therapeutic interventions as prescribed on the master treatment plan to
						  redirect a beneficiary from a psychiatric or behavioral regression or to
						  improve the beneficiary's progress toward specific goal(s) and outcomes. These
						  activities may be either scheduled or
unscheduled as the goal warrants. Services are to be
						  congruent with the age, strengths, necessary accommodations for any disability,
						  and cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
8
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); School (03); Homeless Shelter (04); Assisted
						  Living
Facility (13); Group Home (14); Other Locations
						  (99)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
Start and stop times of actual encounter
						  with beneficiary
.
Date of service
.
Place of service, (If 99 is used,
						  specific location and rationale for location must be included)
.
Client diagnosis necessitating
						  intervention
.
Brief mental status and
						  observations
.
Document how interventions used address
						  goals and objectives from the master treatment plan
.
Beneficiary's response to intervention
						  that includes current progress or regression and prognosis
.
Any changes indicated for the master
						  treatment plan, diagnosis, or medication(s)
.
Plan for next intervention, including
						  any homework assignments
.
Staff signature/credentials/date of
						  signature(s)
NOTES and COMMENTS:
Interventions of a type that
						  could be performed by a paraprofessional may not be billed at a mental health
						  professional rate unless the medical necessity for higher level staff is
						  clearly documented.
H2015
U6
Intervention, Mental Health Professional
Apply the above definition and requirements.
Additional information: Use code H2015 with modifier
						  "U6" to claim for services provided to beneficiaries ages 21 and over.
H2015
U7
Intervention, Mental Health Professional
Apply the above definition and requirements.
Additional information: Use code H2015 with modifier
						  "U7" to claim for services provided via telemedicine only. Note: Telemedicine
						  POS 99
H2015
HA, U1
SERVICE: Intervention, Mental Health
						  Paraprofessional (formerly On-Site and Off-Site Intervention, Mental Health
						  Paraprofessional)
DEFINITION:
Face-to-face, medically
						  necessary treatment activities provided to a beneficiary consisting of specific
						  therapeutic interventions prescribed on the master treatment plan, which are
						  expected to accomplish a specific goal or objective listed on the
master treatment plan. These activities may be either
						  scheduled or unscheduled as the goal or objective warrants. Services are to be
						  congruent with the age, strengths, necessary accommodations for any disability,
						  and cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED:
8
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Beneficiary's
Home (12); School (03); Homeless Shelter (04); Assisted
						  Living
Facility (13); Group Home (14); Other Locations
						  (99)
AGE GROUP(S):
U21
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for
additional requirements):
.
Date of service
.
Start and stop times of actual encounter
						  with beneficiary
.
Place of service (If 99 is used,
						  specific location and rationale for location must be included)
.
Client diagnosis necessitating
						  intervention
.
Document how interventions used address
						  goals and objectives from the master treatment plan
.
Beneficiary's response to intervention
						  that includes current progress or regression and prognosis
.
Plan for next intervention, including
						  any homework assignments
.
Staff signature/credentials/date of
						  signature(s)
NOTES and COMMENTS:
Billing for this service does not
						  include time spent transporting the beneficiary to a required service, nor does
						  it include time spent waiting while a beneficiary attends a scheduled or
						  unscheduled appointment. Supervision by a Mental Health Professional must be
						  documented and addressed in personnel files in accordance with the agency's
						  policies, quality assurance procedures, personnel performance evaluations,
						  reports of supervisors, or other equivalent documented method of
						  supervision.
H2015
U2
Intervention, Mental Health
						  Paraprofessional
Apply the above definition and requirements.
Additional information: Use code H2015 with modifier
						  "U2" to claim for services provided to beneficiaries ages 21 and over
H2017
HA, U1
SERVICE: Rehabilitative Day Service for Persons
						  under Age 18
DEFINITION:
An array of face-to-face
						  interventions providing a preplanned and structured group program for
						  identified beneficiaries that improve emotional and behavioral symptoms of
						  youth diagnosed with childhood disorders, as distinguished from the symptom
						  stabilization function of acute day treatment. These interventions are person-
						  and family-centered, age-appropriate, recovery based, culturally competent,
						  must reasonably accommodate disability, and must have measurable
						  outcomes.
These activities are designed to assist the beneficiary
						  with compensating for or eliminating functional deficits and interpersonal
						  and/or environmental barriers associated with their mental illness. The intent
						  of these services is to enhance a youth's functioning in the home, school, and
						  community with the least amount of ongoing professional intervention. Skills
						  addressed may include: emotional skills, such as coping with stress, anxiety,
						  or anger; behavioral skills, such as positive peer interactions, appropriate
						  social/family interactions, and managing overt expression of symptoms like
						  impulsivity and anger; daily living and self-care skills, such as personal care
						  and hygiene, and daily structure/use of time; cognitive skills, such as problem
						  solving, developing a positive self-esteem, and reframing, money management,
						  community integration, understanding illness, symptoms and the proper use of
						  medications; and any similar skills required to implement a beneficiary's
						  master treatment plan .
DAILY MAXIMUM UNITS THAT MAY BE BILLED:
16
						  for ages 0-17
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED:
80 for ages 0-17
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  School (03); Assisted Living Facility (13); Group Home (14); Other Locations
						  (99) (churches, community centers, space donated solely for clinical services,
						  and appropriate community locations tied to the beneficiary's treatment
						  plan).
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT
						  RATIOS:
1:10 ratio maximum with the provision that client ratio
						  must be reduced when necessary to accommodate significant issues related to
						  acuity, developmental status and clinical needs.
AGE GROUP(S):
U18
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Start and stop times of actual program
						  participation by beneficiary
.
Date of service
.
Place of service
.
Client diagnosis necessitating
						  intervention
.
Behavioral observations
.
Document how
						  interventions used address goals and objectives from the master treatment plan
.
Beneficiary's participation and response to the intervention
.
Staff signature/credentials
.
Supervising staff
						  signature/credentials/date of signature(s)
.
a weekly summary
						  describing therapeutic activities provided and the beneficiary's progress or
						  lack of progress in achieving the treatment goal(s) and established outcomes to
						  be accomplished
NOTES and COMMENTS:
Providers may bill for
						  services only at times during which beneficiaries participate in program
						  activities. Providers are expected to sign beneficiaries in and out of
						  the
program to provide medically necessary treatment
						  therapies. However, in order to be claimed separately, these therapies must be
						  identified on the Master Treatment Plan and serve a treatment purpose which
						  cannot be accomplished within the day treatment setting.
H2017
-
Rehabilitative Day Service for Persons Ages
						  18-20
Apply the above definition and requirements (except
						  Staff to Client Ratios, which are outlined below).
Additional information: Use code H2017 with no modifier
						  to claim for services provided to beneficiaries for ages 18-20.
DAILY MAXIMUM UNITS THAT MAY BE BILLED:
24
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED:
120
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT
						  RATIOS:
1:15 ratio maximum with the provision that client ratio
						  must be reduced when necessary to accommodate significant issues related to
						  acuity, developmental status and clinical needs.
H2017
-
SERVICE: Adult Rehabilitative Day Service
DEFINITION:
An array of face-to-face
						  interventions providing a preplanned and structured group program for
						  identified beneficiaries that aimed at long-term recovery and maximization of
						  self-sufficiency, as distinguished from the symptom stabilization function of
						  acute day treatment. These interventions are person-and family-centered,
						  recovery based, culturally competent, provide needed accommodation for any
						  disability and must have measurable outcomes. These activities assist the
						  beneficiary with compensating for or eliminating functional deficits and
						  interpersonal and/or environmental barriers associated with their chronic
						  mental illness. The intent of these services is to restore the fullest possible
						  integration of the beneficiary as an active and productive member of his/her
						  family, social and work community and/or culture with the least amount of
						  ongoing professional intervention. Skills addressed may include: emotional
						  skills, such as coping with stress, anxiety, or anger; behavioral skills, such
						  as proper use of medications, appropriate social interactions, and managing
						  overt expression of symptoms like delusions or hallucinations; daily living and
						  self-care skills, such as personal care and hygiene, money management, and
						  daily structure/use of time; cognitive skills, such as problem solving,
						  understanding illness and symptoms, and reframing; community integration skills
						  and any similar skills required to implement a beneficiary's master treatment
						  plan .
DAILY MAXIMUM UNITS THAT MAY BE BILLED:
24
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED:
120
PRIOR
						  AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE:
Office (11);
						  Assisted Living Facility (13); Group Home (14); Other Locations (99) (churches,
						  community centers, space donated solely for clinical
services, and appropriate community locations tied to
						  the beneficiary's treatment plan).
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT
						  RATIOS:
1:15 ratio maximum with the provision that client ratio
						  must be reduced when necessary to accommodate significant issues related to
						  acuity, developmental status and clinical needs.
AGE GROUP(S):
Ages 21 and over
DOCUMENTATION REQUIREMENTS (See Section
						  226.200 for additional
						  requirements):
.
Date of service
.
Start and stop times of actual program
						  participation by beneficiary
.
Place of service
.
Client diagnosis necessitating
						  intervention
.
Behavioral observations
.
Document how interventions used address
						  goals and objectives from the master treatment plan
.
Beneficiary's participation and response
						  to the intervention
.
Staff signature/credentials
.
Supervising staff
						  signature/credentials/date of signature(s)
.
A weekly summary describing therapeutic
						  activities provided and the beneficiary's progress or lack of progress in
						  achieving the treatment goal(s) and established outcomes to be accomplished
						  through participation in rehabilitative day service.
NOTES and COMMENTS:
Rehabilitative Day services do NOT include vocational services and
						  training, academic education, personal care or home health services, purely
						  recreational activities and may NOT be used to supplant services which may be
						  obtained or are required to be provided by other means. Providers may bill for
						  services only at times during which beneficiaries participate in program
						  activities. Providers are expected to sign beneficiaries in and out of the
						  program to provide medically necessary treatment therapies. However, in order
						  to be claimed separately, these therapies must be identified on the Master
						  Treatment Plan and serve a treatment purpose which cannot be accomplished
						  within the day treatment setting.
252.140
Telemedicine RSPMI Services
			 Billing Information
The mental health professional may provide certain treatment
				services from a remote site to the Medicaid-eligible beneficiary age 21 or over
				who is located in a mental health clinic setting. See Section
				252.410 for billing
				instructions.
The following services may be provided via telemedicine by a
				mental health professional, bill with POS 99:
National Code
Required Modifier
Local Code
Local Code Description
90801
U7
Z0560
Mental Health Evaluation/Diagnosis
90887
U3, U7
Z0564
Interpretation of Diagnosis
H0004
U7
Z0568
Individual Psychotherapy
90846
U7
Z0571
Marital/Family Psychotherapy - Beneficiary is not
						  present
90847
U7
Marital/Family Psychotherapy - Beneficiary is
						  present
H2011
U7
Z1536
Crisis Intervention
T1023
U7
Z1537
Psychiatric Diagnostic Assessment
H2011
U2, U7
Crisis Stabilization Intervention, Mental Health
						  Professional
H2015
U7
Z1540
Intervention, Mental Health Professional
90862
U7
Z1545
Pharmacologic Management by a Physician
90887
U7
Z1547
Collateral Intervention, Mental Health
						  Professional
252.150
Services Available to Residents of Long Term Care Facilities Billing
Information
The following RSPMI procedure codes are payable to an RSPMI
				provider for services provided to residents of nursing homes who are Medicaid
				eligible when prescribed according to policy guidelines detailed in this
				manual:
National Code
Required Modifier
Local Code
Local Code Description
90801
U1
Z0560
Mental Health Evaluation/Diagnosis
90885
HA, U2
Master Treatment Plan
90885
HA
Periodic Review of Master Treatment Plan
90885
HA, U1
Periodic Review of Master Treatment Plan
90887
U2
Z0564
Interpretation of Diagnosis
H0004
-
Z0568
Individual Psychotherapy
H2011
U7
Z1536
Crisis Intervention
Services provided to nursing home residents may be provided on
				or off site from the RSPMI provider. The services may be provided in the
				long-term care (LTC) facility, if
				necessary.