Rehabilitative Mental Health and Substance Use Disorder (SUD) Services
Rehabilitative mental health and substance use disorder (SUD) services are provided under the authority of §1905(a)(13) of the Social Security Act and 42 CFR §440.130, Diagnostic, Screening, Preventive, and Rehabilitative Services. In accordance with §1905(a)(13) of the Social Security Act, outpatient rehabilitative mental health and SUD services may be provided in settings other than the provider’s office, as appropriate.
In this manual, the term ‘behavioral health’ will include both mental health disorders and SUDs unless otherwise specified. When mental health disorders or SUDs are referred to separately, the term ‘mental health’ or ‘SUD’ will be used.
Rehabilitative mental health and SUD services are designed to promote the Medicaid member’s behavioral health and to restore the individual to the highest possible level of functioning. Services must be provided to or directed exclusively toward the treatment of the Medicaid member.
Rehabilitative behavioral health services may be provided to Medicaid members with a dual diagnosis of a mental health disorder and/or SUD and an intellectual disability, developmental disorder or related condition when the services are directed to the treatment of the mental health disorder or SUD.
Accountable Care Organization (ACO) means a Utah managed care organization that contracts with Division of Integrated Healthcare to provide medical services to Medicaid members.
Adult Expansion Medicaid Members mean parents and adults without dependent children earning up to 138% of the federal poverty level.
Behavioral health disorders means mental health disorders and substance use disorders (SUDs).
Behavioral health services mean the rehabilitative services directed to the treatment of the mental health disorders and/or SUDs.
Centers for Medicare and Medicaid Services (CMS) means the agency within the federal Department of Health and Human Services that administers the Medicare and Medicaid programs, and works with states to administer the Medicaid program.
Children in Foster Care means children and youth under the statutory responsibility of the Utah Department of Health and Human Services identified as such in the Medicaid eligibility (eREP) system.
CPT manual means the Current Procedural Terminology CPT Professional Edition or CPT Professional Codebook, published by the American Medical Association.
DHHS means the Utah Department of Health and Human Services.
Division of Integrated Healthcare (DIH) means the organizational unit in DHHS that administers the Medicaid program in Utah. Before July 1, 2022, this was the Division of Medicaid and Health Financing in the Utah Department of Health. Beginning July 1, 2022, this is the Division of Integrated Healthcare in DHHS.
Division of Occupational and Professional Licensing (DOPL) means the division within the Utah State Department of Commerce responsible for occupational and professional licensing.
Early Periodic Screening Diagnostic and Treatment (EPSDT) means the federally mandated program that provides comprehensive and preventive health care services for children under age 21. For more information on EPSDT, refer to the Utah Medicaid Provider Manual for EPSDT Services.
Enrollee means any Medicaid member enrolled in the Prepaid Mental Health Plan (PMHP), UMIC Plan or HOME.
Fee-for-Service (FFS) means Medicaid-covered services that are reported directly to and paid directly through FFS Medicaid based on an established fee schedule.
Habilitation Services typically means interventions for the purpose of helping individuals acquire new functional abilities whereas rehabilitative services are for the purpose of restoring functional losses. (See Rehabilitative Services definition below.)
Healthy Outcomes Medical Excellence Program (HOME), operated by the University of Utah, means a voluntary managed care program for Medicaid members who have a developmental disability and mental health or behavioral challenges. HOME is a coordinated care program that provides to its enrollees medical services, behavioral health services, and targeted case management services.
Institution of Mental Diseases (IMD) means pursuant to 42 CFR §435.1010, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for individuals with intellectual disabilities is not an institution for mental diseases.
Medically Necessary Services means any rehabilitative service that is necessary to diagnose, correct, or ameliorate a behavioral health disorder or prevent deterioration or development of additional behavioral-health problems, and there is no other equally effective course of treatment available or suitable that is more conservative or substantially less costly.
Prepaid Mental Health Plan (PMHP) means the mental health and substance use disorder managed care plan operating under the authority of the Department of Health and Human Services's 1915(b) waiver.
Presumptive Eligibility means temporary Medicaid coverage for qualified low-income individuals prior to establishing eligibility for ongoing Medicaid.
Rehabilitative Services means any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts (i.e. licensed mental health therapist) for maximum reduction of an individual’s behavioral health disorder and restoration of the individual to his/her best possible functional level.
SUMH means the Office of Substance Use and Mental Health in the Division of Integrated Healthcare.
Targeted Adult Medicaid Members means adults age 19-64 without dependent children whose income is zero percent of the Federal Poverty Level and who meet the criteria for one of the following groups: (1) chronically homeless individuals, (2) individuals involved in the justice system and in need of SUD or mental health treatment, or (3) individuals in need of SUD or mental health treatment.
Treatment Goals means measures of progress decided jointly with the patient whenever possible and may also be referred to as measurable goals or measurable objectives. For purposes of this provider manual, the term ‘treatment goals’ will be used to specify the measures contained in treatment plans.
Utah Medicaid Integrated Care (UMIC) Plans mean managed care plans responsible to provide both physical health services and behavioral health services (i.e., mental health and substance use disorder services) to their enrollees. HOME is not a UMIC plan.
Utah operates a behavioral health managed care plan under a federal freedom-of-choice waiver. This managed care plan is called the Prepaid Mental Health Plan (PMHP).
Under the PMHP, DIH contracts with local county mental health and substance abuse authorities or their designated entities to provide inpatient hospital psychiatric services, and outpatient mental health and outpatient substance use disorder services to Medicaid members.
The PMHP covers most counties of the state. Medicaid members are automatically enrolled with the PMHP contractor serving their county of residence, and must receive inpatient and outpatient mental health services and outpatient substance use disorder services through that PMHP contractor. See Table 1 of this Chapter for PMHP coverage. Under Utah’s 1115 Demonstration Waiver, Adult Expansion Medicaid members in certain counties of the state are enrolled in UMIC Plans, and must receive behavioral health services through their UMIC Plans. See Table 2 of this Chapter for UMIC Plan coverage.
Prior to delivering services, providers must verify eligibility and determine if a member is enrolled in the PMHP or a UMIC Plan. For tools to verify eligibility, refer to Chapter 6, ‘Member Eligibility’, of Utah Medicaid Provider Manual, Section I: General Information. If a Medicaid member is enrolled in the PMHP or a UMIC Plan, and the provider is not on the member’s PMHP or UMIC Plan panel, the provider must refer the member to the PMHP or UMIC Plan, or contact the PMHP or UMIC Plan prior to delivering services to seek prior authorization.
The tables below show by county whether mental health and substance use disorder services are reimbursed through FFS Medicaid, or whether they are covered under the PMHP or UMIC Plans.
In Table 1, when services are reimbursed through FFS Medicaid, ‘FFS’ is specified. When services are covered under the PMHP, the name of the PMHP contractor is specified.
Table 1 - Mental Health and Substance Use Disorder Services Coverage
|
Counties |
Inpatient & Outpatient Mental Health Services |
Outpatient Substance Use Disorder Services |
|---|---|---|
|
Box Elder, Cache, Rich |
Bear River Mental Health |
FFS |
|
Beaver, Garfield, Kane, Iron, Washington |
Southwest Behavioral Health Center |
Southwest Behavioral Health Center |
|
Carbon, Emery, Grand |
Four Corners Community Behavioral Health |
Four Corners Community Behavioral Health |
|
Daggett, Duchesne, Uintah, San Juan |
Northeastern Counseling Center |
Northeastern Counseling Center |
|
Davis |
Davis Behavioral Health |
Davis Behavioral Health |
|
Piute, Juab, Wayne, Millard, Sanpete, Sevier |
Central Utah Counseling Center |
Central Utah Counseling Center |
|
Salt Lake |
Salt Lake County Division of Behavioral Health Services/Optum |
Salt Lake County Division of Behavioral Health Services/Optum |
|
Summit |
Healthy U Behavioral |
Healthy U Behavioral |
|
Tooele |
Optum Tooele County |
Optum Tooele County |
|
Utah |
Wasatch Behavioral Health |
Wasatch Behavioral Health |
|
Wasatch |
FFS |
FFS |
|
Weber, Morgan |
Weber Human Services |
Weber Human Services |
For PMHP contact information, please refer to the Medicaid Managed Care website at: https://medicaid.utah.gov/managed-care
Adult Expansion Medicaid members living in Davis, Salt Lake, Utah, Washington, and Weber counties are not enrolled in the PMHP. These Medicaid members are enrolled in UMIC Plans that cover both physical health and behavioral health (i.e., mental health and substance use disorder) services.
Table 2 below shows by county, the UMIC Plans Adult Expansion Medicaid members can select for enrollment.
Table 2 - Mental Health and Substance Use Disorder Services – UMIC Plans
|
UMIC Plans by County |
Integrated Health Choice |
Integrated Healthy U |
Integrated Molina |
Integrated SelectHealth |
|---|---|---|---|---|
| County | ||||
|
Davis |
• |
• |
• |
• |
|
Salt Lake |
• |
• |
• |
• |
|
Utah |
• |
• |
• |
• |
|
Washington |
• |
Not Available |
• |
• |
|
Weber |
• |
• |
• |
• |
For UMIC Plan contact information, please refer to the Medicaid Managed Care website at: https://medicaid.utah.gov/managed-care
Adult Expansion Medicaid members living in other counties are enrolled in the PMHP serving their county of residence according to Table 1 above.
Behavioral health services provided by an Indian health care provider operated by Indian Health Services, an Indian Tribe, Tribal Organization, or an Urban Indian Organization to Medicaid members enrolled in UMIC Plans are reimbursed through FFS Medicaid. Authorization from the member’s UMIC Plan is not required.
All Medicaid members enrolled in the PMHP may also get behavioral health services directly from a federally qualified health center (FQHC). FQHCs are reimbursed through FFS Medicaid. Authorization from the member’s PMHP is not required.
Behavioral health services provided by an Indian health care provider operated by Indian Health Services, an Indian Tribe, Tribal Organization, or an Urban Indian Organization are reimbursed through FFS Medicaid. Authorization from the member’s PMHP is not required.
Medicaid members enrolled in the PMHP who are also Medicare beneficiaries may obtain behavioral health services directly from providers who accept Medicare. Authorization from the member’s PMHP is not required. For providers also enrolled as Medicaid providers, crossover claims will be processed through FFS Medicaid, and will be subject to crossover adjudication logic for payment of co-insurance and deductible, if applicable.
Children in Foster Care
Children in Foster Care are enrolled in the PMHP only for inpatient hospital psychiatric services. They are not enrolled in the PMHP for outpatient behavioral health services. They may obtain outpatient services from any qualified Medicaid provider. Providers are reimbursed through FFS Medicaid.
Children with State Adoption Subsidy
Children with state adoption subsidy are enrolled in the PMHP. However, an exemption from PMHP enrollment for outpatient behavioral health services may be granted on a case-by case basis. Once disenrolled, these children remain enrolled in the PMHP only for inpatient hospital psychiatric services. They may obtain outpatient services from any qualified Medicaid provider. Providers are reimbursed through FFS Medicaid.
Medicaid Members Enrolled in HOME
Medicaid members enrolling in HOME are disenrolled from their PMHP or UMIC Plan. HOME enrollees must receive all behavioral health services through HOME (see Chapter 1-2, Definitions). Providers must follow HOME’s network and prior authorization requirements and obtain reimbursement directly from HOME.
Presumptive Eligibility
Medicaid members with presumptive eligibility are not enrolled in the PMHP or UMIC Plans. Providers are reimbursed through FFS Medicaid.
Targeted Adult Medicaid Members
Targeted Adult Medicaid Members are not enrolled in the PMHP or UMIC Plans. Providers are reimbursed through FFS Medicaid.
Evaluations
When mental health evaluations and psychological testing are performed for physical health purposes, including prior to medical procedures, or for the purpose of diagnosing intellectual or developmental disabilities, or organic disorders, they are carved out services from the PMHPs, UMIC Plans and the ACOs.
When these services are performed for the purposes stated above, providers are reimbursed through FFS Medicaid. Providers must include the UC modifier with the procedure code; otherwise, the service will be denied.
For information on mental health evaluations and psychological testing for physical health purposes, also refer to the Utah Administrative Rule R414-10, Physician Services, and the Utah Medicaid Provider Manual for Physician Services.
Note: Additional provider requirements apply when evaluations may be used to qualify a Medicaid member to receive Medicaid-covered autism spectrum disorder (ASD)-related services. For information on these requirements and on ASD-related services, refer to the Utah Medicaid Provider Manual for Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals.
This carve-out policy does not apply to: (1) developmental screenings performed as part of a preventive EPSDT service (see the Utah Medicaid Provider Manual for EPSDT Services); and (2) psychiatric consultations performed during a physical health inpatient hospitalization. The ACOs remain responsible for these services.
This carve-out policy does not apply to mental health evaluations and psychological testing for the primary purpose of diagnosing or treating behavioral health disorders. The PMHPs and UMIC Plans remain responsible for these services.
This carve-out policy does not apply to HOME enrollees. If the Medicaid member is enrolled in HOME, refer to the section above on HOME enrollment.
Methadone Administration Services
Methadone administration services are not covered under the PMHP or UMIC Plans. Medicaid members may obtain methadone administration services from Medicaid-enrolled Opioid Treatment Programs (OTPs). OTPs are reimbursed through FFS Medicaid. However, related outpatient behavioral health services that Medicaid members require are covered under the PMHP and UMIC Plans.
Behavioral health services are limited to medically necessary services directed to the treatment of behavioral health disorders (see Chapter 1-2 for definition of behavioral health disorders). Services must be provided to the Medicaid member or directed exclusively toward the treatment of the Medicaid member.
Telemedicine:
Services may be provided via telemedicine when clinically appropriate. Services must be provided in accordance with telemedicine policy contained in the Utah Medicaid Provider Manual, Section I: General Information. For dates of service prior to April 1, 2022, when services are provided by telemedicine, providers must specify place of service ‘02’ in the place of service field on the claim. For dates of service on or after April 1, 2022, providers must specify the place of service as follows:
The scope of rehabilitative behavioral health services includes the following:
See Chapter 2, Scope of Services, for service definitions and limitations.
When applicable to a provider in A. or B. below, providers are responsible to ensure supervision is provided in accordance with requirements set forth in Title 58 of the Utah Code, and the applicable profession’s practice act rule as set forth by the Utah Department of Commerce and found at the Department of Administrative Services, Division of Administrative Rules, at: https://rules.utah.gov/publications/utah-adm-code.
Providers Qualified to Prescribe Behavioral Health Services
Rehabilitative services must be prescribed by an individual defined below:
Providers Qualified to Render Services
In accordance with the limitations set forth in Chapter 2, Scope of Services, rehabilitative services may be provided by:
Training Requirements for Other Trained Individuals
Other trained individuals may provide psychosocial rehabilitative services (see Chapter 2-11) and for Prepaid Mental Health Plans and UMIC Plans, the services included in Chapter 3.
These individuals must receive training in order to be a qualified provider. The hiring body must ensure the following minimum training requirements are met:
Individuals shall receive training on all administrative policies and procedures of the agency, and the program as applicable, including:
2.Individuals shall also receive information and training in areas including:
The hiring body shall maintain documentation of training including dates of training, agendas and training/educational materials used.
The supervising provider must ensure individuals complete all training within 60 calendar days of the hiring date, or for existing providers within 60 calendar days from the date of enrollment as a Medicaid provider.
In accordance with state law, individuals identified in Chapter 1–5, A. are qualified to conduct an evaluation (psychiatric diagnostic evaluation). Evaluations are performed for the purpose of assessing and determining diagnoses, and as applicable, identifying the need for behavioral health services. (See Chapter 2-2, Psychiatric Diagnostic Evaluation.)
When evaluations performed in accordance with Chapter 2-2, Psychiatric Diagnostic Evaluation, may be used to qualify an individual to receive Medicaid-covered autism spectrum disorder (ASD)-related services, additional provider requirements apply. For information on these requirements and on ASD-related services, refer to the Utah Medicaid Provider Manual for Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals.
For information and requirements regarding evaluations for individuals with a condition requiring chronic pain management services, refer to the Utah Medicaid Provider Manual for Physician Services, Chapter 2, Covered Services. For evaluations required prior to certain surgical procedures, refer to Chapter 1-3, Medicaid Behavioral Health Service Delivery System, Evaluations Not Covered by the PMHP, in this manual, and to the Utah Medicaid Provider Manual for Physician Services, Chapter 2, Covered Services
For psychotherapy with patient and psychotherapy with evaluation and management (E/M services) the CPT Manual requires that the patient be present for all or a majority of the service. For psychotherapy for crisis, the CPT Manual requires that the patient be present for all or some of the service. See Psychiatry section of the CPT Manual, and the ‘Limits’ sections of Chapters 2-5, 2-6 and 2-7.
Other services can involve the participation of others but are provided for the direct benefit of the patient. The service must actively involve the patient in the sense of being tailored to the patient’s individual needs. There may be times when, based on clinical judgment, the patient is not present during the delivery of the service, but remains the focus of the service.
The progress note must specify that the service was a collateral service and document how the identified patient was the focus of the session. Other documentation requirements under the ‘Record’ section of the applicable service also apply.
A range of dates should not be reported on a single line of a claim if the dates overlap months (e.g., 4/1 through 5/15). Each month's services should be reported separately to ensure proper adjudication of the claim.
For dates of service prior to April 1, 2022, when services are provided by telemedicine, providers must specify place of service ‘02’ in the place of service field on the claim. For dates of service on or after April 1, 2022, providers must specify the place of service as follows:
When providers listed in Chapter 1-5 are not qualified to practice independently, third party payers may require that behavioral health services they provide be billed in the name and NPI of their licensed supervisor. This is also an allowed practice when reporting services to DIH.
CMS has implemented a correct coding initiative that includes two editing modules: the Procedure-to-Procedure (PTP) module and the Medically Unlikely Edits (MUE) module.
Procedure-to-Procedure (PTP) Editing
This editing applies when two services are provided by the same servicing provider on the same day. This module contains a list of procedure code combinations where generally the second service is considered incident to the first service in the procedure code combination. Unless otherwise specified, the provider may not receive separate reimbursement for the second service. When the second service in the code combination cannot be reimbursed separately, the two procedure codes are followed by a ‘0’ in the third column.
For some procedure code combinations, NCCI will allow reimbursement of the second procedure in the combination if the two services are actually separate and distinct services. When CMS allows reimbursement for both procedure codes in the combination, the two procedure codes are followed by a ‘1’ in the third column. In these instances, a provider must use a modifier on the claim to indicate the two services provided were separate and distinct.
When NCCI also allows the second procedure in the procedure combination to be reimbursed, providers must include the ‘59’ modifier on the claim in order to obtain reimbursement for the second service. Please refer to CPT manual for information on the 59 modifier.
Medically Unlikely Edits
The MUE module contains units-of-service edits. For specified procedure codes, NCCI has set a limit on the number of units of service that may be reimbursed.
NCCI Editing Updates
CMS may update these two modules quarterly. To review the PTP and MUE modules, providers may go to the CMS website at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Index.html. For information on procedure-to-procedure editing, select the NCCI Coding Edits link, then under Related Links, select the Physician CCI Edits link for the effective quarter. For information on medically unlikely edits, select the Medically Unlikely Edits link, and then under Related Links, select the Practitioner Services MUE Table link for the effective quarter. Follow the prompts to access the files.
For information on quarterly additions, deletions and revisions to these modules, select the Quarterly NCCI and MUE Version Update Changes link for the effective quarter. For procedure-to-procedure editing updates, under Related Links, select the Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI Edits for Physicians/Practitioners link for the effective quarter. For medically unlikely editing updates, under Related Links, select the Quarterly Additions, Deletions, and Revisions to Published MUEs for Practitioner Services, for the effective quarter. Since CMS can update the PTP and MUE modules quarterly, providers are responsible to be familiar with the edits in these modules.
Behavioral health services are covered benefits when the services are medically necessary services. Behavioral health services include psychiatric diagnostic evaluation, mental health assessment by a non-mental health therapist, psychological testing, psychotherapy with patient, family psychotherapy with patient present and family psychotherapy without patient present, group psychotherapy, multiple family group psychotherapy, psychotherapy for crisis, psychotherapy with evaluation and management (E/M) services, evaluation and management (E/M) services (i.e., pharmacologic management), therapeutic behavioral services, psychosocial rehabilitative services, peer support services, SUD residential treatment, assertive community treatment (ACT) and assertive community outreach treatment (ACOT), mobile crisis outreach teams (MCOT), clinically managed residential withdrawal management, mental health residential treatment, and behavioral health receiving centers. For treatment of SUDs, these services cover the American Society of Addiction Medicine (ASAM) levels of care 1.0, 2.1, 2.5, 3.1, 3.3, 3.5 and 3.7.
Service Coverage and Reimbursement Limitations
Information on service coverage and reimbursement limitations is available in the web-based lookup tool entitled, Coverage & Reimbursement Lookup Tool, located at: http://health.utah.gov/stplan/lookup/CoverageLookup.php. The Coverage & Reimbursement Lookup Tool contains up-to-date information on coverage, limits, prior authorization requirements, etc. The tool also includes a special notes section that includes any additional information regarding the service, including any manual review requirements associated with the service. This tool allows providers to search for coverage and reimbursement information by HCPCS/ Current Procedural Terminology (CPT) procedure code, date of service and provider type. The ‘Limits’ sections in Chapter 2 in this manual will address other types of limits and clarifications related to the services.
See Chapter 10 of the Utah Medicaid Provider Manual, Section I: General Information for information on prior authorization. Also see the Coverage & Reimbursement Lookup Tool located at: http://health.utah.gov/stplan/lookup/CoverageLookup.php for information on prior authorization for these procedure codes.
Psychiatric diagnostic evaluation means a face-to-face evaluation for the purpose of assessing and determining diagnoses, and as applicable identifying the need for behavioral health services. The evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations, with interpretation and report. The evaluation may include communication with family or other sources and review and ordering of diagnostic studies. In certain circumstances one or more other informants (family members, guardians or significant others) may be seen in lieu of the patient.
Psychiatric diagnostic evaluation with medical services also includes medical assessment and other physical examination elements as indicated and may be performed only by qualified medical providers specified in the ‘Who’ section of this chapter below.
In accordance with the CPT manual, codes 90791 (psychiatric diagnostic evaluation) and 90792 (psychiatric diagnostic evaluation with medical services) are used for the diagnostic assessment(s) or reassessment(s), if required.
Because ongoing assessment and adjustment of psychotherapeutic interventions are part of psychotherapy, reassessments including treatment plan reviews occurring in psychotherapy session may be coded as such. (See definition of psychotherapy and the ‘Record’ section of Chapter 2-5, Psychotherapy.
If based on the evaluation it is determined behavioral health services are medically necessary, an individual qualified to perform this service is responsible for the development of an individualized treatment plan. An individual qualified to perform this service also is responsible to conduct reassessments/treatment plan reviews with the patient as clinically indicated to ensure the patient’s treatment plan is current and accurately reflects the patient’s rehabilitative goals and needed behavioral health services. (See Chapter 1-7, Treatment Plans.)
See Chapter 2-6, Psychotherapy for Crisis, for information on reporting urgent assessments of a crisis state as defined under Psychotherapy for Crisis.
Who:
licensed physician assistant specializing in mental health care in accordance with Section 58-70a-501 of the Utah Code.
When this service is performed to determine the need for medication prescription only, it also may be performed by:
Limits:
Procedure Codes and Unit of Service:
90791 - Psychiatric Diagnostic Evaluation - per 15 minutes
90792 - Psychiatric Diagnostic Evaluation with Medical Services, - per 15 minutes
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
+90785 – Interactive Complexity Add-On Code - per service
In accordance with the CPT manual, CPT code 90785 is an add-on code for interactive complexity. It may be reported in conjunction with 90791 and 90792. There is no additional reimbursement for this add-on code.
Record:
Documentation must include:
Mental Health Assessment means providers listed below, participating as part of a multi-disciplinary team, assisting in the psychiatric diagnostic evaluation process defined in Chapter 2-2, Psychiatric Diagnostic Evaluation. Through face-to-face contacts, the provider assists in the psychiatric diagnostic evaluation process by gathering psychosocial information including information on the individual’s strengths, weaknesses and needs, and historical, social, functional, psychiatric, or other information and assisting the individual to identify treatment goals. The provider assists in the psychiatric diagnostic reassessment/treatment plan review process specified in Chapter 2-2 by gathering updated psychosocial information and updated information on treatment goals and assisting the patient to identify additional treatment goals. Information also may be collected through in-person or telephonic interviews with family/guardians or other sources as necessary. The information obtained is provided to the individual identified in Chapter 2-2 who will perform the assessment, reassessment or treatment plan review.
Who:
The following individuals when under the supervision of a licensed mental health therapist identified in Chapter 1-5, A. 1 qualified to provide supervision in accordance with state law:
Limits:
Procedure Code and Unit of Service:
H0031 – Mental Health Assessment by a Non-Mental Health Therapist – per 15 minutes
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Documentation must include:
Psychological testing means evaluation to determine the existence, nature and extent of a mental illness or other disorder using psychological tests appropriate to the individual’s needs, with interpretation and report.
Who:
Limits:
NCCI MUE and PTP limits would apply. See Chapter 1-11, Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI).
Procedure Codes and Unit of Service:
Assessment of Aphasia and Cognitive Performance Testing
96105 - Assessment of Aphasia - includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading spelling, writing, e.g., by Boston Diagnostic Aphasia Examination, with interpretation and report, per hour
96125 - Standardized Cognitive Performance Testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report, per hour.
Developmental/Behavioral Screening and Testing
96110 - Developmental Screening – Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument
96112 - Developmental Test Administration – Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory, and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report, first hour
+96113 - Each additional 30 minutes (List separately in addition to code for primary procedure, 96112)
Psychological/Neuropsychological Testing
Neurobehavioral Status Examination
96116 - Neurobehavioral Status Examination - Clinical assessment of thinking, reasoning and judgement, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report, first hour
+96121 - Each additional hour (List separately in addition to code for primary procedure, 96116)
Testing Evaluation Services
Psychological Testing
96130 - Psychological Testing Evaluation - services by physician or other qualified health care professional, including integration of data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed, first hour
+96131 - Each Additional Hour (List separately in addition to code for primary procedure, 96130)
Neuropsychological Testing
96132 - Neuropsychological testing evaluation - services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed, first hour
+96133 - Each additional hour (List separately in addition to code for primary procedure, 96132)
Testing Administration and Scoring
96136 - Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
+96137 - Each additional 30 minutes (List separately in addition to code for primary procedure, 96136)
96138 - Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes
+96139 - Each additional 30 minutes (List separately in addition to code for primary procedure, 96138)
Automated Testing and Result
96146 - Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only.
CPT Time Rules
The time reported under 96116, 96121, 96130, 96131, 96132, 96133, and 96125 also includes the face-to-face time with the patient.
In order to report the per hour codes (96105, 96125, 96112, 96116, 96121, 96130, 96131, 96132, and 96133), a minimum of 31 minutes of service must be provided.
In order to report the 30-minute codes (96113, 961136, 96137, 96138, and 96139) a minimum of 16 minutes of service must be provided.
Report the total time at the completion of the entire episode of evaluation.
Record:
Documentation must include:
Psychotherapy means the treatment for mental illness and behavioral disturbances in which the clinician through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development so that the patient may be restored to his/her best possible functional level. Services are based on measurable treatment goals identified in the treatment plan.
Psychotherapy codes 90832-90838 include ongoing assessment and adjustment of psychotherapeutic interventions, and may include involvement of informants in the treatment process.
Psychotherapy includes psychotherapy with the patient, family psychotherapy with patient present, family psychotherapy without patient present, group psychotherapy and multiple-family group psychotherapy.
Psychotherapy with patient means in accordance with the definition of psychotherapy face-to-face interventions with the patient.
Family psychotherapy with patient present means in accordance with the definition of psychotherapy face-to-face interventions with family members and the identified patient with the goal of treating the patient’s condition and improving the interaction between the patient and family members so that the patient may be restored to their best possible functional level.
Family psychotherapy without patient present means in accordance with the definition of psychotherapy face-to-face interventions with family members without the identified patient present with the goal of treating the patient’s condition and improving the interaction between the patient and family members so that the patient may be restored to their best possible functional level.
Group psychotherapy means in accordance with the definition of psychotherapy face-to-face interventions with two or more patients or two or more families in a group setting so that the patients may be restored to their best possible functional level.
Who:
Psychotherapy with patient
Limits:
In accordance with the CPT manual, the following limits apply:
Procedure Codes and Unit of Service:
90832 – Psychotherapy, 30 minutes, with patient - per encounter
90834 – Psychotherapy, 45 minutes, with patient - per encounter
90837 – Psychotherapy, 60 minutes, with patient - per encounter
The following time rules apply for converting the duration of the service to the appropriate procedure code:
90832 - 16 through 37 minutes;
90834 - 38 through 52 minutes; and
90837 - 53 minutes through 89 minutes.
Prolonged Services Add-on Codes:
In accordance with the CPT manual, for psychotherapy services not performed with an E/M service of 90 minutes or longer face-to-face with the patient, providers may use the appropriate prolonged services add-on code(s) specified below with psychotherapy code 90837 depending on the duration and place of the psychotherapy service.
+99354 – first hour (60 additional minutes with patient); and
+99355 – each additional 30 minutes with patient (beyond the 60 additional minutes that are coded with 99354)
In accordance with the CPT manual coding requirements for prolonged services, if the psychotherapy is provided in a nursing facility or other setting where the Nursing Facility Services range of E/M services codes would be used for E/M services (E/M codes 99304-99310), then prolonged services add-on codes 99356/99357 are used for the additional psychotherapy time. (In the event psychotherapy is provided to a patient in an inpatient setting, these prolonged services codes would also be used.)
+99356 – first hour (60 additional minutes with the patient); and
+99357 – each additional 30 minutes with patient (beyond the 60 additional minutes that are coded with 99356)
In accordance with CPT requirements, prolonged service of less than 30 minutes total duration on a given date is not separately reported. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
The following time rules apply for converting the duration of the service to the appropriate prolonged services add-on procedure code(s):
Less than 30 minutes equals 0 units;
30 minutes through 74 minutes (30 minutes through 1 hour 14 minutes) equals 1 unit of 99354 or 99356;
75 minutes through 104 minutes (1 hour 15 minutes through 1 hour 44 minutes) equals 1 unit of 99354 or 99356 plus 1 unit of 99355 or 99357; and
105 minutes through 134 minutes (1 hour 45 minutes through 2 hours 14 minutes) equals 1 unit of 99354 or 99356 plus 2 units of 99355 or 99357, etc.
+90785 – Interactive Complexity Add-on Code - per service
In accordance with the CPT manual, CPT code 90785 is an add-on code for interactive complexity. It may be reported in conjunction with 90832, 90834 and 90837. There is no additional reimbursement for this add-on code.
Record:
Documentation must include:
Family psychotherapy with patient present and family psychotherapy without patient present
Procedure Codes and Unit of Service:
90846 - Family Psychotherapy - without patient present – per 15 minutes
90847 - Family Psychotherapy - with patient present – per 15 minutes
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Documentation must include:
Group psychotherapy and multiple-family group psychotherapy
Limits:
Procedure Codes and Unit of Service:
90849 - Multiple-Family Group Psychotherapy - per 15 minutes per Medicaid patient
90853 - Group Psychotherapy - per 15 minutes per Medicaid patient
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
+90785 – Interactive Complexity Add-on Code - per service
In accordance with the CPT manual, CPT code 90785 is an add-on code for interactive complexity. It may be reported in conjunction with 90853. There is no additional reimbursement for this add-on code.
Record:
Documentation must include:
Psychotherapy for crisis means a face-to-face service with the patient and/or family and includes an urgent assessment and history of a crisis state and disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to an individual in high distress. Providers may use CPT coding for this service if the crisis and interventions qualify for this coding.
Who:
Licensed mental health therapist or an individual exempted from licensure as a mental health therapist. (See Chapter 1-5, B. 1.)
Limits:
In accordance with the CPT manual, the following limits apply:
This service cannot be reported in conjunction with procedure code 90791, 90792, psychotherapy codes 90832-90838 or other psychiatric services or 90785-90899. Under CMS’ NCCI, this means this service and these other services cannot both be reimbursed when provided on the same day by the same servicing provider.
Procedure Codes and Unit of Service:
90832 – Use for psychotherapy for crisis services of 30 minutes or less total duration on a given date even if the time spent on that date is not continuous, or 90833 when provided with E/M services. (See #4 of Limits above.)
90839 – Psychotherapy for crisis, first 60 minutes, per encounter
The following time rules apply for converting the total duration of the service to the appropriate procedure code:
90839 - 31 through 74 minutes total duration on a given date even if the time spent on that date is not continuous
Psychotherapy for Crisis Add-on Code: 90840 –
In accordance with the CPT manual, for psychotherapy for crisis, code 90840 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes, which is reported with code 90839:
+90840 – each additional 30 minutes – per encounter
The following time rules apply for converting the total duration of the service to the psychotherapy for crisis add-on code:
+90840 – 75 minutes through 104 minutes (1 hour 15 minutes through1 hour 44 minutes) equals 1 unit (in addition to the unit of 90839);
105 minutes through 134 minutes (1 hour 45 minutes through 2 hours 14 minutes) equals 2 units (in addition to the unit of 90839); and
135 minutes through 164 minutes (2 hours 15 minutes through 2 hours 44 minutes) equals 3 units (in addition to the unit of 90839), etc.
Record:
Documentation must include:
Psychotherapy with E/M services means psychotherapy with the patient when performed with an E/M service on the same day by the same provider. (See Chapter 2-8 for information on E/M services.)
Psychotherapy add-on codes 90833, 90836, and 90838 include ongoing assessment and adjustment of psychotherapeutic interventions, and may include involvement of informants in the treatment process.
Who:
Limits:
In accordance with the CPT manual, the two services must be significant and separately identifiable and may be separately identified as follows:
The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision-making;
Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service (i.e., time spent on history, examination and medical decision-making when used for the E/M service is not psychotherapy time). Time may not be used as the basis of E/M code selection and prolonged services may not be reported when psychotherapy with E/M (psychotherapy add-on codes 90833, 90836, 90838) are reported; and
Procedure Codes and Unit of Service:
In accordance with the CPT manual, psychotherapy performed with an E/M service is coded using the applicable psychotherapy add-on code specified below with the applicable E/M code (E/M codes are specified in Chapter 2-8). The psychotherapy add-on code must be on the same claim as the E/M service procedure code.
+90833 – Psychotherapy, 30 minutes, with patient when performed with an E/M service – per encounter
+90836 – Psychotherapy, 45 minutes, with patient when performed with an E/M service - per encounter
+90838 – Psychotherapy, 60 minutes, with patient when performed with an E/M service – per encounter
The following time rules apply for converting the duration of the service to the appropriate procedure code:
+90833 - 16 through 37 minutes;
+90836 - 38 through 52 minutes; and
+90838 - 53 minutes and longer
+90785 – Interactive Complexity Add-on Code- per service
In accordance with the CPT manual, CPT code 90785 is an add-on code for interactive complexity. It may be reported in conjunction with psychotherapy when performed with an E/M service (90833, 90836 and 90838). There is no additional reimbursement for this add-on code.
Record:
For the psychotherapy portion of the service, documentation must include:
Refer to Chapter 2-8 for documentation requirements for the E/M portion of the service.
Pharmacologic management means reviewing and monitoring the patient’s prescribed medication(s) and medication regimen to manage a behavioral health condition. Reviewing and monitoring includes evaluation of dosage, effect the medication(s) is having on the patient’s symptoms, and side effects. Any of the following may also be included in the service: prescription of medications to treat the patient’s behavioral health condition, providing information (including directions for proper and safe usage of medications), and/or administering medications as applicable. The service can also address other health issues as applicable.
Who:
Limits:
Procedure Codes and Unit of Service:
This service is provided in accordance with the CPT coding for E/M services. (Please refer to the E/M services section of the CPT manual for complete information on E/M services.)
Use of CG Modifier with E/M Services codes
When reporting this pharmacologic management service, use the CG modifier with the E/M code. The CG modifier signifies that the service was a behavioral health pharmacologic management service as opposed to a medical E/M service.
It is important to use the CG modifier with the E/M code so that the applicable managed care edit (i.e., PMHP, UMIC Plan or HOME) will post to the claim in the event a claim is inadvertently submitted FFS for a member who is enrolled in managed care. If a claim is submitted FFS without the CG modifier, then the applicable managed care edit (i.e., ACO, UMIC Plan or HOME) will post to the claim, as the absence of the CG modifier signifies the E/M service was for medical purposes.
If a Medicaid member is enrolled in an ACO and a PMHP, and the provider is a primary care provider (i.e., not a behavioral health provider), the provider should bill the Medicaid member’s ACO even if the E/M visit addresses a medication prescribed for a behavioral health condition, as it is recognized that primary care providers can prescribe and manage these medications. Providers should consult the ACO(s) regarding prior authorization and billing requirements.
See Chapter 1-3, ‘Medicaid Behavioral Health Delivery System’ for information on managed care coverage.
Office or Other Outpatient Services E/M Codes -
The following codes are used to report E/M services provided in the office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs.
Established Patient Codes
99211 – per encounter - E/M of an established patient; usually the presenting problems are minimal.
99212- per encounter - E/M of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213 – per encounter - E/M of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214 – per encounter - E/M of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215 – per encounter – E/M of an established patient, which requires a medically appropriate history and /or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.
Subsequent Nursing Facility Care E/M Codes
The following codes are used to report E/M services to patients in nursing facilities (formerly called skilled nursing facilities [SNFs], intermediate care facilities [ICFs], or long-term care facilities [LTCFs]).
These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential center (a facility or a distinct part of a facility for psychiatric care, which provides 24-hour therapeutically planned and professionally staffed group living and learning environment).
Established Patient Codes
99307- per encounter - Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the patient is stable, recovering or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99308 – per encounter- Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99309 – per encounter - Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99310 – per encounter – Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
Home Services E/M Codes
The following codes are used to report E/M services provided in a private residence.
Established Patient Codes
99347- per encounter - E/M of an established patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99348 – per encounter - E/M of an established patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99349 – per encounter - E/M of an established patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
99350 – per encounter – E/M of an established patient, which requires at least 2 of these 3 key components:
*Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family.
*Please refer to the definition of Counseling in the E/M section of the CPT manual.
Prolonged Services Add-on Codes 99354-99357 and 99417:
In accordance with the CPT manual, prolonged services add-on codes 99354-99357 may be reported in addition to the designated E/M codes at any level, except the E/M codes in the Office or Other Outpatient Services range (when prolonged services add-on code 99417 is to be used).
If the duration of the E/M service with the patient and/or family is longer than the typical time associated with an E/M code, then prolonged services add-on coding may apply.
For example, in accordance with rules for prolonged services add-on codes, if the E/M service qualifying for coding as 99350 is 90 minutes or longer, then the E/M code plus the applicable prolonged services add-on code(s) would be reported depending on the duration and the place of service. Refer to the time rules below and to the Prolonged Services section of the CPT manual for additional information.
In accordance with the CPT manual, the following prolonged services codes are used depending on the E/M place of service and duration.
Limits:
In accordance with the CPT manual, the following limits apply:
Procedure Codes and Unit of Service:
In accordance with the CPT manual, the following prolonged services codes are used depending on the E/M place of service and duration:
Office or Other Outpatient Services E/M codes and Home Services E/M codes:
+99354- first hour (60 additional minutes with patient); and
+99355- each additional 30 minutes with the patient (beyond the 60 additional minutes that are coded with 99354)
Prolonged Services Add-on Code 99417
In accordance with the CPT manual, 99417 is used for reporting prolonged services only with the longest timed E/M codes in the Office or Other Outpatient Services ranges and is only used when the E/M service code is selected based on time alone, and not on medical decision making. In the Established Patient code range, 99417 may be reported with the longest timed E/M code 99215 when the time spent is 55 minutes or longer.
Procedure Codes and Unit of Service:
+99417- per 15 minutes
The following time rules apply for converting the duration of the service to prolonged services add-on code 99417 when coded with 99215:
Less than 55 minutes - not reported;
55-69 minutes equals 99215 and 1 unit of 99417;
70-84 minutes equals 99215 and 2 units of 99417;
85 or more minutes equals 3 or more units of 99417 for each additional 15 minutes.
Subsequent Nursing Facility Care E/M codes (and any inpatient-based E/M codes in the event the E/M service is provided to a patient in an inpatient setting):
+99356 – first hour (60 additional minutes with patient); and
+99357- each additional 30 minutes with the patient (beyond the 60 additional minutes that are coded with 99356)
The following time rules apply for converting the total duration of the prolonged service to the appropriate prolonged services add-on procedure code(s):
Less than 30 minutes equals 0 units;
30 minutes through 74 minutes (30 minutes through 1 hour 14 minutes) equals 1 unit of 99354 or 99356;
75 minutes through 104 minutes (1 hour 15 minutes through 1 hour 44 minutes) equals 1 unit of 99354 or 99356 plus 1 unit of 99355 or 99357; and
105 minutes through 134 minutes (1 hour 45 minutes through 2 hours 14 minutes) equals 1 unit of 99354 or 99356 plus 2 units of 99355 or 99357, etc.
Record:
Nurse medication management means reviewing and monitoring the patient’s prescribed medication(s) and medication regimen to manage a behavioral health condition. Reviewing and monitoring includes evaluation of dosage, effect the medication(s) is having on the patient’s symptoms, and side effects. Any of the following may also be included in the service: providing information (including directions for proper and safe usage of medications), and/or administering medications as applicable. The service can also address other health issues as applicable.
Who:
Limits:
Procedure Codes and Unit of Service:
T1001- Nurse Evaluation and Assessment – per encounter
96372- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
Record:
Documentation must include:
Therapeutic behavioral services are provided face-to-face to an individual or group of patients and means services that do not fully meet the definition of psychotherapy. Instead, the provider uses behavioral interventions to assist patients with specific behavior problems.
Who:
Limits:
Procedure Codes and Unit of Service:
H2019 - Individual/Family Therapeutic Behavioral Services - per 15 minutes
H2019 with HQ modifier - Group Therapeutic Behavioral Services - per 15 minutes per Medicaid patient
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Documentation must include:
Psychosocial rehabilitative services (PRS) are provided face-to-face to an individual or group of patients and means services that are designed to restore the patient to his or her maximum functional level through the use of face-to-face interventions such as cueing, modeling, and role-modeling of appropriate fundamental daily living and life skills. This service is aimed at maximizing the patient’s basic daily living and life skills, increasing compliance with the medication regimen as applicable, and reducing or eliminating symptomatology that interferes with the patient’s functioning. Intensive psychosocial rehabilitative services may be reported when a ratio of no more than five patients per provider is maintained during a group rehabilitative psychosocial service.
Who:
Limits:
Intensive PRS groups are limited to five patients per provider, with a maximum of ten patients per intensive PRS group. Intensive PRS groups are planned, structured groups independent from other PRS groups, and are designed to address the clinical needs of patients who, if in regular PRS groups would be distracting to other group members and/or require more individualized attention, including one on one, to maintain their focus on their clinical issues and treatment goals. Intensive PRS cannot be coded based solely on the number of patients in attendance.
The psychiatric diagnostic evaluation or other clinical documentation must document the need for an intensive PRS group, the patient's diagnoses, severity of symptoms and behaviors, and why an intensive PRS group is required. The treatment plan must prescribe intensive PRS and contain goals to ameliorate the symptoms and behaviors that necessitate intensive PRS group.
Procedure Codes and Unit of Service:
H2014 – Individual Skills Training and Development - per 15 minutes (This procedure code is used when providing PRS to an individual patient.)
H2017 - Group Psychosocial Rehabilitative Services - per 15 minutes per Medicaid patient
H2017 with U1 modifier - Group Psychosocial Rehabilitative Services – Intensive - per 15 minutes per Medicaid patient (See #3 of ‘Limits’ section above.)
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
*Psychosocial rehabilitative services provided in licensed day treatment or licensed residential treatment programs:
Because patients may leave and return later in the day (e.g., to attend other services, for employment, etc.), if attendance in each group meets the minimum time requirement for reporting (i.e., at least eight minutes), then time spent throughout the day may be totaled to determine units of service provided for reporting purposes. If attendance in some groups does not meet the eight-minute minimum, then those groups may not be included in the daily total for determining the amount of time spent and the number of units to be reported.
Record:
Group Psychosocial Rehabilitative Services Provided in Licensed Day Treatment Programs, Licensed Residential Treatment Programs, and Licensed or Unlicensed Day Treatment Programs in Schools
Because rehabilitation is a process over time requiring frequent repetition and practice to achieve goals, progress is often slow and intermittent. Consequently, there must be sufficient amounts of time for progress to be demonstrated.
Therefore, at a minimum, one summary note for each unique type of psychosocial rehabilitative group the patient participated in during the immediately preceding two-week period must be prepared at the close of the two-week period. The required
summary note may be written by the provider who provided the group, or by a provider who is most familiar with the patient’s involvement and progress across groups.
The summary note must include:
name of the group;
treatment goal(s) addressed in the group and the patient’s progress toward treatment goal(s) or if there was no reportable progress, documentation of reasons or barriers; and
signature and licensure or credentials of the individual who prepared the documentation. If a co-leader is present for the group, the note must contain the co-leader’s name and licensure or credentials.
If the provider prefers, the
provider may follow the documentation requirements listed under the next section, section B.
Psychosocial Rehabilitative Services Provided to a Group of Patients in Other Settings
When psychosocial rehabilitative services are provided to groups of patients outside of an organized day treatment or residential treatment program, for each unique type of psychosocial rehabilitative group and for each group session, documentation must include:
date, start and stop time, and duration of the group;
setting in which the group was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth);
specific service rendered (i.e., psychosocial rehabilitative services) and the name of the group (e.g., relationship skills group, etc.);
treatment goal(s) addressed in the group and the patient’s progress toward treatment goal(s) or if there was no reportable progress, documentation of reasons or barriers; and
signature and licensure or credentials of the individual who rendered the service. If a co-leader is present for group, the note must contain the co-leader’s name and licensure or credentials.
Psychosocial Rehabilitative Services Provided to an Individual
When provided to an individual patient, for each service documentation must include:
date, start and stop time, and duration of the service;
setting in which the service was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth);
specific service rendered (i.e., psychosocial rehabilitative services)
treatment goal(s);
treatment goal(s) addressed in the session and the patient’s progress toward treatment goal(s) or if there was no reportable progress, documentation of reasons or barriers; and
signature and licensure or credentials of the individual who rendered the service.
If psychosocial rehabilitative services goals are met as a result of participation in the service, then if applicable, new individualized goals must be added to the treatment plan.
Peer support services means face-to-face services for the primary purpose of assisting in the rehabilitation and recovery of patients with behavioral health disorders. For children, peer support services are provided to their parents/legal guardians as appropriate to the child’s age when the services are directed exclusively toward the treatment of the Medicaid-eligible child. Peer support services are provided to an individual or group of patients, or parents/legal guardians.
On occasion, it may be impossible to meet with the peer support specialist in which case a telephone contact with the patient or parent/legal guardian of a child would be allowed.
Peers support services are designed to promote recovery. Peers offer a unique perspective that patients find credible; therefore, peer support specialists are in a position to build alliances and instill hope. Peer support specialists lend their unique insight into mental illness and substance use disorders and what makes recovery possible.
Using their own recovery stories as a recovery tool, peer support specialists assist patients with creation of recovery goals and with goals in areas of employment, education, housing, community living, relationships and personal wellness. Peer support specialists also provide symptom monitoring, assist with symptom management, provide crisis prevention, and assist patients with recognition of health issues impacting them.
Peer support services must be prescribed by a licensed mental health therapist identified in paragraph A of Chapter 1-5. Peer support services are delivered in accordance with a written treatment/recovery plan that is a comprehensive, holistic, individualized plan of care developed through a person-centered planning process. Patients lead and direct the design of their plans by identifying their own preferences and individualized measurable recovery goals.
Who:
Peer support services are provided by certified peer support specialists.
To become a certified peer support specialist, an individual must:
Certified peer support specialists are under the supervision of a licensed mental health therapist identified in paragraph A.1 or A.2.b. of Chapter 1-5; or a licensed ASUDC or a licensed SUDC when peer support services are provided to patients with a SUD.
Supervisors must provide ongoing weekly individual and/or group supervision to the certified peer support specialists they supervise.
Limits:
Procedure Code and Unit of Service:
H0038 – Individual Peer Support Services - per 15 minutes
H0038 with HQ modifier - Group Peer Support Services - per 15 minutes per Medicaid patient
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Documentation must include:
If peer support services goals are met as a result of participation in the service, then if applicable, new individualized goals must be added to the treatment plan;
Utah’s 1115 Demonstration Waiver waives federal Institution for Mental Disease (IMD) exclusions for licensed SUD residential treatment programs with 17 or more beds. This means that licensed SUD residential treatment programs with 17 or more beds are eligible for Medicaid reimbursement. This also means that Medicaid members age 21 through 64 in these larger programs are now eligible for Medicaid reimbursement. Reimbursement is made on a per diem bundled payment basis.
Licensed SUD residential treatment programs with 16 or fewer beds are also reimbursed on a per diem bundled payment basis.
SUD residential treatment means face-to-face services that are a combination of medically necessary services provided in accordance with Chapters 2-2 through 2-12 of this manual, and in accordance with the Utah Medicaid Provider Manual for Targeted Case Management Services for Individuals with Serious Mental Illness. Services must be individualized, and provided according to each patient’s ASAM assessment/reassessment and treatment plan in order to treat the patient’s documented SUD.
These programs are responsible to ensure appropriate transitions to other levels of outpatient SUD services either by directly providing the level of care needed or by coordinating the transition to the needed level of care with another FFS provider. For PMHP, UMIC Plan and HOME enrollees, the program must coordinate transitions to other levels of outpatient SUD services with the enrollee’s PMHP or UMIC Plan, or with HOME.
These programs, regardless of number of beds, must report services using the per diem procedure codes specified in the ‘Procedure Codes and Unit of Service’ below.
Who:
Programs licensed as a substance use disorder residential treatment program in accordance with Section 62A-2-101 of the Utah Code.
The following individuals, in accordance with their licensure or credentials, may perform the services delivered in the licensed SUD residential treatment program:
Limits:
Prior Authorization (PA)
FFS Medicaid Members
All licensed SUD residential treatment programs, regardless of the number of beds, must request PA in accordance with PA policy and procedures contained in the Utah Medicaid Provider Manual, Section I: General Information, Chapter 10-1, ‘Request Prior Authorization’, and Chapter 5 of this manual.
Prepaid Mental Health Plan (PMHP), Utah Medicaid Integrated Care (UMIC) Plan and HOME Enrollees
PMHPs, UMIC Plans, and HOME may also implement utilization review, including prior authorization of services. For information on PMHPs’, UMIC Plans’, and HOME’s PA and utilization review requirements and processes, programs must contact these plans.
Procedure Codes and Unit of Service:
Programs with 17 or more beds: H0018 – Behavioral health; short-term residential (non-hospital residential treatment program), without room and board – per diem (Alcohol and/or drug services), per Medicaid patient
Programs with 16 or fewer beds: H2036 - Alcohol and/or drug treatment program, per diem, per Medicaid patient
Record:
Assertive Community Treatment (ACT) and Assertive Community Outreach Treatment (ACOT) means an evidence-based psychiatric rehabilitation practice that provides a comprehensive approach to service delivery to patients with serious mental illness. Services are provided by a multidisciplinary team of providers whose backgrounds and training include psychiatry, nursing, social work or other related mental health therapist field, and rehabilitation. The entire team shares responsibility for each patient, with each team member contributing expertise as appropriate. The team approach ensures continuity of care for patients and creates a supportive environment for providers. ACT and ACOT teams are characterized by low patient-to-staff ratios, provide services in community, provider 24/7 staff availability, provider services directly rather than referring patients to other agencies, and provide services on a time unlimited basis.
Who:
The ACT and ACOT teams consist of the following positions: team lead, prescriber, nurse, mental health therapist, SUD counselor, certified peer support specialist, other mental health professionals (e.g., certified targeted case managers), employment specialist, and program assistant.
Limits:
Procedure Code and Unit of Service:
H0040 – Assertive Community Treatment, per month
Record:
Documentation must include:
Mobile Crisis Outreach Team (MCOT) means a mobile team defined by Administrative Rule R523-18 that consists of at least two members who are deployed to the community to perform behavioral health crisis evaluations. Based on the assessment, the team also coordinates with local law enforcement, emergency medical service personnel, and other appropriate state or local resources.
Who:
An MCOT certified through the SUMH that meets the standards set forth in Administrative Rule, R523-18, and that includes:
The MCOT must also have access to a designated examiner and a medical professional for consultation during the MCOT response in accordance with Rule R523-18 of the Utah Code.
Limits:
Procedure Code and Unit of Service:
H2000 – Comprehensive multidisciplinary evaluation, per diem
Record:
Documentation must include:
Clinically Managed Residential Withdrawal Management, sometimes referred to as “social detox”, means 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal and are appropriated to be managed in a social setting. This level of care emphasizes peer and social supports rather than medical and nursing care. Staff trained in withdrawal signs and symptoms of alcohol and other drug intoxication and withdrawal monitor the patients. Programs rely on established clinical protocols to identify patients in need of medical services beyond the capacity of the facility and transfer such patients to a more appropriate level of care. Programs have access to 24-hour medical and nursing supports.
Who:
A program that is licensed through DHHS, Office of Licensing, as a social detoxification facility, meets the ASAM Criteria guidelines for level 3.2-WM, and includes the following staff under the clinical management of a licensed mental health therapist identified in Chapter 1-5, A. 1:
Limits:
Effective July 1, 2021, for Medicaid members enrolled in PMHPs, UMIC Plans, or HOME, social detoxification is covered under these plans. See Chapter 1-3, ‘Medicaid Behavioral Health Service Delivery System’ for more information. For Medicaid members not enrolled in one of these plans, providers are reimbursed through FFS Medicaid.
PMHPs, UMIC Plans, and HOME may also implement utilization review, including prior authorization of services. For information on PMHPs’ , UMIC Plans’, and HOME’s PA and utilization review requirements and processes, programs must contact these plans.
Procedure Code and Unit of Service:
H0012 – Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient)
Record:
Documentation must include:
Mental health residential treatment means face-to-face services that are a combination of medically necessary services provided in accordance with Chapters 2-2 through 2-12 of this manual, and the Utah Medicaid Provider Manual for Targeted Case Management Services for Individuals with Serious Mental Illness, as applicable. Services must be individualized and provided according to each patient’s assessment /reassessment and treatment plan in order to treat the patient’s documented mental health disorder.
Programs with 17 or More Beds
Utah’s 1115 Demonstration Waiver waives federal Institution for Mental Disease (IMD) exclusions for licensed mental health residential treatment programs with 17 or more beds that are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the Commission on Accreditation of Rehabilitation Facilities (CARF).
This means that licensed and accredited residential treatment programs with 17 or more beds are eligible for Medicaid reimbursement for Medicaid members age 21 through 64. Reimbursement is made on a per diem bundled payment basis and is available for admissions on or after January 1, 2021.
In accordance with the 1115 Demonstration Waiver, these programs must have the capacity to address co-morbid physical health conditions during short-term stays in residential treatment settings (e.g., with on-site staff, telemedicine, and/or partnerships with the patient’s ACO or UMIC Plan, HOME, or a FFS provider if not enrolled in a plan).
These programs are also responsible to ensure appropriate transitions to other levels of outpatient mental health services either by directly providing the level of care needed or by coordinating the transition to the needed level of care with another FFS provider. For PMHP, UMIC Plan and HOME enrollees, the program must coordinate transitions to other levels of outpatient mental health services with the enrollee’s PMHP or UMIC Plan, or with HOME.
These programs must have a process to assess the housing situation of the patient transitioning to the community from the program and to connect the patient who may experience homelessness upon discharge or who would be discharged to unsuitable or unstable housing with community providers that coordinate housing services.
These programs must have protocols in place to ensure contact is made with each discharged patient within 72 hours of discharge and to help ensure the patient accesses follow-up care by contacting the community-based provider they were referred to.
Programs must report services using the per diem procedure code specified in the ‘Procedure Codes and Unit of Service’ section below.
Programs with 16 or Fewer Beds
Effective April 1, 2021, for Medicaid members 21 years of age or older, licensed mental health residential treatment programs with 16 or fewer beds are also reimbursed on a per diem bundled payment basis.
To allow for time to transition to the use of the per diem bundled procedure code, for dates of service on or after January 1, 2022, these programs must begin using the per diem bundled procedure code specified in the ‘Procedure Codes and Unit of Service’ section below.
For Medicaid members under 21 years of age, there are no changes. Providers must continue to report the individual services provided in accordance with Chapters 2-2 through 2-12 of this manual.
Who:
Programs licensed as a mental health residential treatment program in accordance with Section 62A-2-101 of the Utah Code.
The following individuals, in accordance with their licensure or credentials, may perform the services delivered in the licensed mental health residential treatment program:
Limits:
Prior Authorization (PA)
FFS Medicaid Members
Prepaid Mental Health Plan (PMHP), Utah Medicaid Integrated Care (UMIC) Plan, and HOME Enrollees
For programs with 17 or more beds, PMHPs, UMIC Plans, and HOME must implement utilization review, including prior authorization of services. For information on PMHPs’, UMIC Plans’, and HOME’s PA and utilization review requirements and processes, programs must contact these plans.
These managed care plans may also require PA for programs with 16 or fewer beds. Programs must contact the plans for information on PA requirements.
Procedure Codes and Unit of Service:
Programs with 17 or more beds: H0017 – Behavioral health; residential (hospital residential treatment program), without room and board – per diem, per Medicaid patient
Programs with 16 or fewer beds: H2013 – Psychiatric health facility service- per diem, per Medicaid patient 21 years of age or older
Record:
Licensed mental health residential treatment programs must maintain the following documentation:
Behavioral Health Receiving Centers (receiving centers) are centers that provide services to individuals experiencing a behavioral health crises in the community. Receiving centers are staffed 24 hours a day, 365 days a year. Receiving centers must adhere to Rule R523-21 of the Utah Administrative Code. Receiving centers are reimbursed through FFS Medicaid.
Who:
Limits:
None.
Procedure Code and Unit of Service:
S9485 – Crisis intervention mental health services; per diem
Record:
Documentation must include:
This Chapter applies only to PMHP contractors, UMIC Plans, and HOME.
The services contained in this Chapter are authorized under the PMHP Section 1915(b) Waiver, under Utah's 1115 Demonstration Waiver for UMIC Plans, and under Section 1915(a) authority for HOME. The services are available only to Medicaid members enrolled in the PMHP, HOME, or UMIC Plans.
For PMHPs, these services are not a benefit for Medicaid members enrolled in the PMHP for only inpatient psychiatric care. This includes children in foster care, and children with adoption subsidy exempted from the PMHP for outpatient behavioral health services.
In accordance with Chapter 1-7, Treatment Plan, the services below must be included on the patient’s treatment plan that must meet requirements of Chapter 1-7.
Personal Services are recommended by a physician or other practitioner of the healing arts (see paragraph A of Chapter 1-5) and are furnished for the primary purpose of assisting in the rehabilitation of patients with serious mental illness (SMI) or serious emotional disorder (SED). These services include assistance with instrumental activities of daily living (IADLs) that are necessary for patients to live successfully and independently in the community and avoid hospitalization. Personal services include assisting the patient with varied activities based on the patient’s rehabilitative needs: picking up prescriptions, income management, maintaining the living environment including cleaning and shopping, and the transportation related to the performance of these activities, and representative payee activities when the PMHP, UMIC Plan, or HOME, or one of their providers has been legally designated as the patient’s representative payee. These services assist patients to achieve their goals for remedial and/or rehabilitative IADL adequacy necessary to restore them to their best possible functioning level.
Who:
Procedure Code and Unit of Service:
H0046 – per 15 minutes
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Documentation must include:
Respite care is recommended by a physician or practitioner of the healing arts (see Chapter 1-5, A) and is furnished face-to-face to a child for the primary purpose of giving the parent(s)/guardian(s) temporary relief from the stresses of caring for a child with a serious emotional disorder (SED). Respite care can prevent parent/guardian burn-out, allow for time to be spent with other children in the family, preserve the family unit, and minimize the risk of out-of-home placement by reducing the stress families of children with SED typically encounter.
Who:
Procedure Code and Unit of Service:
S5150 – per 15 minutes
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Each provider delivering respite care must provide documentation as follows:
Psychoeducational Services are recommended by a physician or practitioner of the healing arts (see Chapter 1-5, A) and are provided face-to-face to an individual or group of patients and are furnished for the primary purpose of assisting in the rehabilitation of patients with serious mental illness (SMI) or serious emotional disorders (SED). This rehabilitative service includes interventions that help patients achieve goals of remedial and/or rehabilitative vocational adequacy necessary to restore them to their best possible functioning level.
Who:
Procedure Code and Unit of Service:
H2027 – Psychoeducational Services - per 15 minutes per Medicaid patient
The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.
Record:
Because rehabilitation is a process over time requiring frequent repetition and practice to achieve goals, progress is often slow and intermittent. Consequently, there must be sufficient amounts of time for progress to be demonstrated.
Therefore, at a minimum, one summary note for each preceding two-week period during which the patient received psychoeducational services must be prepared at the close of the two-week period.
The summary note must include:
name of the service;
treatment goal(s) addressed in the service and progress toward treatment goal(s) or if there was no reportable progress, documentation of reasons or barriers; and
signature and licensure or credentials of the individual who rendered the service.
If the provider prefers, the provider may follow the documentation requirements listed under the next section, section B.
Psychoeducational Services Provided to a Group of Patients in Other Settings
When psychoeducational services are provided to groups of patients outside of an organized day treatment or residential treatment program, for each psychoeducational group session, documentation must include:
date, start and stop time, and duration of the psychoeducational group;
Setting in which the group was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth);
specific service rendered;
treatment goal(s) addressed in the group and the patient’s progress toward treatment goal(s) or if there was no reportable progress, documentation of reasons or barriers; and
signature and licensure or credentials of the individual who rendered the service.
Psychoeducational Services Provided to an Individual
When provided to an individual patient, for each service documentation must include:
date, start and stop time, and duration of the service;
setting in which the service was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth);
specific service rendered;
treatment goal(s) addressed in the service and progress toward treatment goal(s) or if there was no reportable progress, documentation of barriers; and
signature and licensure or credentials of the individual who rendered the service.
If psychoeducational services goals are met as a result of participation in the service, then if applicable, new individualized goals must be added to the treatment plan.
Psychoeducational services provided in licensed day treatment or licensed residential treatment programs:
Because patients may leave and return later in the day (e.g., to attend other services, for employment, etc.), in accordance with Chapter 1-12, if attendance in each psychoeducational services group meets the minimum time requirement for reporting (i.e., at least eight minutes), then time spent throughout the day may be totaled to determine units of service provided for reporting purposes. If attendance in some groups does not meet the eight-minute minimum, then those groups may not be included in the daily total for determining the amount of time spent and the number of units to be reported.
Supportive Living means costs incurred in licensed residential treatment programs or licensed residential support programs when enrollees are placed in these programs.
Costs include those incurred for 24-hour staff, facility costs associated with providing individual Covered Services (e.g., individual psychotherapy, pharmacologic management, etc.) at the facility site, and apportioned administrative costs. Costs do not include the covered services costs or room and board costs. This level of care is recommended by a physician or other practitioner of the healing arts (see Chapter 1-5, A), and helps to restore patients with serious mental illness (SMI) or SED to their best possible functioning level. PMHPs, UMIC Plans, and HOME will provide this level of care when needed so that individuals may remain in a less restrictive community setting.
Supportive living may not be reported when a per diem bundled residential treatment code is reported in accordance with Chapter 2-13 or Chapter 2-17 (codes H0018, H2036, H0017, and H2013) as supportive living costs are included in the bundled payment rates.
Who:
Limits:
Supportive living may not be reported for licensed SUD residential treatment programs reported with bundled procedure codes H0018 or H2036, for licensed mental health residential treatment programs reported with bundled procedure codes H0017 or H2013, or for clinically managed residential withdrawal management (ASAM Level 3.2-WM) social detoxification programs reported with bundled procedure code H0012. See Chapters 2-13, 2-17 and 2-16.
Procedure Code and Unit of Service:
H2016 – 1 unit per day
Record:
Documentation must include:
|
Procedure Code |
Service and Units |
|---|---|
|
90791** |
Psychiatric Diagnostic Evaluation - per 15 minutes |
|
90792** |
Psychiatric Diagnostic Evaluation with Medical Services - per 15 minutes |
|
H0031 |
Mental Health Assessment by Non-Mental Health Therapist - per 15 minutes |
|
96130** |
Psychological testing evaluation services by physician or other qualified health care professional - first hour |
|
96131** |
Each additional hour of 96130 |
|
96132** |
Neuropsychological testing evaluation services by physician or other qualified health care professional - first hour |
|
96133** |
Each additional hour of 96132 |
|
96136** |
Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes |
|
96137** |
Each additional 30 minutes of 96136 |
|
96138** |
Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes |
|
96139** |
Each additional 30 minutes of 96138 |
|
96146** |
Psychological or neuropsychological test administration with single automated, standardized instrument via electronic platform, with automated result only, encounter |
|
96105** |
Assessment of Aphasia - per hour |
|
96125** |
Standardized cognitive performance testing – per hour |
|
96110** |
Developmental Screening - per standardized instrument |
|
96112** |
Developmental test administration – first hour |
|
96113** |
Each additional 30 minutes of 96112 |
|
96116** |
Neurobehavioral Status Exam - first hour |
|
96121** |
Each additional hour of 96116 |
|
90832 |
Psychotherapy with patient and/or family member - 30 minutes |
|
90834 |
Psychotherapy with patient and/or family member - 45 minutes |
|
90837 |
Psychotherapy with patient and/or family member - 60 minutes |
|
90846 |
Family Psychotherapy - without patient present - per 15 minutes |
|
90847 |
Family Psychotherapy - with patient present - per 15 minutes |
|
90849 |
Group Psychotherapy - Multiple-family group psychotherapy - per 15 minutes per Medicaid patient |
|
90853 |
Group Psychotherapy – per 15 minutes per Medicaid patient |
|
90839 |
Psychotherapy for Crisis, first 60 minutes* – per encounter |
|
90840 |
Psychotherapy for Crisis, add-on to 90839, each additional 30 minutes |
|
|
*Note: Use 90832 for crisis contacts 30 minutes or less |
|
90833 |
Psychotherapy add-on code, with patient and/or family member – 30 minutes (added to applicable evaluation and management (E/M) service code) |
|
90836 |
Psychotherapy add-on code, with patient and/or family member – 45 minutes (added to applicable evaluation and management (E/M) service code) |
|
90838 |
Psychotherapy add-on code, with patient and/or family member – 60 minutes (added to applicable evaluation and management (E/M) service code) |
|
99211-99215* |
Office or Other Outpatient Services Evaluation and Management (E/M) Services Codes- established patient |
|
99307-99310* |
Subsequent Nursing Facility Care E/M Codes – established patient (should be used to report E/M services provided to a patient in a psychiatric residential center [a facility or a distinct part of a facility for psychiatric care, which provides 24-hour therapeutically planned and professionally staffed group living and learning environment]) |
|
99347-99350* |
Home Services E/M Codes – established patient
|
|
99354 |
Prolonged Services, first hour (60 additional minutes with patient) - per encounter (Use with E/M codes 99347-99350; and with 90837 when psychotherapy place of service is where these E/M codes would be used.) |
|
99355 |
Prolonged Services, each additional 30 minutes with patient (beyond the 60 additional minutes that are coded with 99354) – per encounter |
|
99356 |
Prolonged Services, first hour (60 additional minutes with patient) - per encounter (Use with E/M codes 99307-99310 or inpatient-based E/M codes; and with 90837 when psychotherapy place of service is where these E/M codes would be used.) |
|
99357 |
Prolonged Services, each additional 30 minutes with patient (beyond the 60 additional minutes that are coded with 99356) – per encounter |
|
99417 |
Prolonged Services- per 15 minutes (Use with Outpatient or Other Outpatient Services E/M code 99215) |
|
T1001 |
Nurse Evaluation and Assessment (Medication Management) - per encounter |
|
96372 |
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug) subcutaneous or intramuscular – per encounter |
|
90785 |
Add-on code for interactive complexity (with procedure codes 90791, 90792, 90832, 90834, 90837, 90833, 90836, 90838; and E/M services codes) |
|
H2019 |
Individual/Family Therapeutic Behavioral Services - per 15 minutes |
|
H2019 with HQ modifier |
Group Therapeutic Behavioral Services - per 15 minutes per Medicaid patient |
|
H2014 |
Individual Skills Training and Development (Psychosocial rehabilitative services with an individual patient) - per 15 minutes |
|
H2017 |
Group Psychosocial Rehabilitative Services - per 15 minutes per Medicaid patient |
|
H2017 with U1 modifier |
Group Psychosocial Rehabilitative Services - Intensive - per 15 minutes per Medicaid patient |
|
H0038 |
Peer Support Services, individual patient – per 15 minutes |
|
H0038 with HQ modifier |
Peer Support Services, group - per 15 minutes per Medicaid patient |
|
H0018 |
Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem |
|
H2036 |
Alcohol and/or drug treatment program, per diem |
|
H0040 |
Assertive Community Treatment (ACT) or Assertive Community Outreach Treatment (ACOT), per month |
|
H2000 |
Comprehensive multidisciplinary evaluation, (MCOT), per diem |
|
H0012 |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) |
|
H0017 |
Behavioral health; residential (hospital residential treatment program), without room and board – per diem, per Medicaid patient |
|
S9485 |
Crisis intervention mental health services; per diem, per Medicaid patient |
|
Prepaid Mental Health Plan Contractors and UMIC Plans Only - 1915(b)(3) Services and Additional Services |
|
|
H0046 |
Personal Services - per 15 minutes |
|
S5150 |
Respite Care - per 15 minutes |
|
H2027 |
Psychoeducational Services – per 15 minutes |
|
H2016 |
Supportive Living – per day |
*CG modifier:
This modifier indicates the service provided was pharmacologic management covered under Chapter 2-8, Pharmacologic Management (Evaluation and Management (E/M) Services).
** UC modifier:
When evaluation or psychological testing is performed for physical health purposes, including prior to medical procedures, or for the purpose of diagnosing intellectual or development disabilities, or organic disorders, the services are carved out of managed care. To ensure correct adjudication of the claim, use the UC modifier with the procedure code.
To prevent the delivery of unnecessary and inappropriate care to Medicaid members who have FFS Medicaid, and to provide for both necessity for care and appropriateness of care requests, a PA process has been implemented to review SUD treatment provided in licensed SUD residential treatment program, ASAM levels of care 3.1, 3.3, 3.5, and 3.7. (See Chapter 2-13, ‘Substance Use Disorder Treatment in Licensed Substance Use Disorder Residential Treatment Programs’, for policy, documentation requirements, and other requirements for licensed SUD residential treatment programs.)
Please refer to the Utah Medicaid Provider Manual, Section I: General Information, Chapter 10, ‘Prior Authorization’, for information regarding prior authorization.
The required PA request form is the SUD Residential Treatment Services Prior Authorization Request Form found at: https://medicaid.utah.gov/forms.
In addition to the Utah Medicaid Provider Manual, Section I: General Information, Chapter 10, ‘Prior Authorization’, see additional PA requirements below.
Admission (Non-Clinical) PA Request
Providers must:
complete the SUD Residential Treatment Services Prior Authorization Request Form found at: https://medicaid.utah.gov/forms, and
request no more than 30 calendar days for adolescent Medicaid members age 12 through age 18; or
request no more than 60 calendar days for adult Medicaid members 19 years of age or older; and
submit the PA request form no later than two business days after the date of admission. No supporting documentation is required.
Note: Members may receive only one non-clinical PA per treatment episode. If a PMHP, UMIC Plan or HOME has given a non-clinical PA and the member’s enrollment changes to FFS during the treatment episode, additional PA requests must be clinical PA requests.
Continued Stay (Clinical) PA Request
When additional days beyond those approved through the non-clinical PA request are medically necessary, providers must:
complete the SUD Residential Treatment Services Prior Authorization Request Form found at https://medicaid.utah.gov/forms, and
request no more than 30 calendar days for adolescent Medicaid members age 12 through age 18; or
request no more than 60 calendar days for adult Medicaid members 19 years of age or older;
complete an ASAM reassessment and treatment plan review no earlier than seven calendar days of (and including) the first requested date of service indicated on the PA request form. Documentation must be completed in accordance with #3 and #4 of the ‘Record’ section of Chapter 2-13; and
submit the PA request form, ASAM reassessment and treatment plan review no later than the first date of service requested on the PA request form.
Note: Members may receive only one admission (non-clinical) PA per treatment episode. If a PMHP, UMIC Plan or HOME has given a non-clinical PA and the member’s enrollment changes to FFS during the treatment episode, additional PA requests must be continued stay (clinical) PA requests.
Transition Days
If the provider determines that medical necessity for continued stay is not met, the provider may request up to 14 calendar transition days to allow time to transition the member to the medically necessary ASAM level of care. Providers must:
complete the PA request form and ensure that the ‘Additional Information’ section indicates that the request is for transition days; and
submit the PA request form no later than the first date of service requested on the PA request form.
If the PA Unit determines that the clinical documentation submitted with a continued stay (clinical) PA request does not support continued stay, the PA Unit may authorize up to14 calendar days to allow time to transition the member to the medically necessary ASAM level of care.
Member Absence from the Program
Absence of three calendar days or less:
Providers must request a modification to the current PA request by completing and submitting a new SUD Residential Treatment Services Prior Authorization Request Form found at: https://medicaid.utah.gov/forms. Ensure the following are completed:
‘Previous Authorization Information’ section; and
‘Additional Information’ section, including the dates the member was absent.
Absence of more than three calendar days:
Providers must request a new non-clinical PA by following the instructions in the Non-Clinical Prior Authorization (PA) Request section above. Ensure the following are completed:
‘Previous Authorization Information’ section; and
‘Additional Information’ section, including the date the member left the program.
To prevent the delivery of unnecessary and inappropriate care to Medicaid members who have FFS Medicaid, and to provide for both necessity for care and appropriateness of care requests, a PA process has been implemented to review mental health treatment provided in licensed and accredited mental health residential treatment programs with 17 or more beds. (See Chapter 2-17, ‘Mental Health Treatment in Licensed Mental Health Residential Treatment Programs’, for policy and other requirements for licensed mental health residential treatment programs.) This policy and prior authorization requirements in this chapter do not apply to psychiatric hospitals.
Please refer to the Utah Medicaid Provider Manual, Section I: General Information, Chapter 10, ‘Prior Authorization’, for information regarding prior authorization.
The required PA request form is the Mental Health Residential Treatment Services – Individuals Age 21-64 Prior Authorization Request Form found at: https://medicaid.utah.gov/forms
In addition to the Utah Medicaid Provider Manual, Section I: General Information, Chapter 10, ‘Prior Authorization’, see additional PA requirements below.
Admission (Non-Clinical) PA Request
Providers must:
complete the Mental Health Residential Treatment Services – Individuals Age 21-64 Prior Authorization Request Form found at: https://medicaid.utah.gov/forms, and
Note: Members may receive only one non-clinical PA per treatment episode. If a PMHP, UMIC Plan or HOME has given a non-clinical PA and the member’s enrollment changes to FFS during the treatment episode, additional PA requests must be clinical PA requests.
Continued Stay (Clinical) PA Request
When additional days beyond those approved through the non-clinical PA request are medically necessary, providers must:
complete the Mental Health Residential Treatment Services – Individuals Age 21-64 Prior Authorization Request Form found at: https://medicaid.utah.gov/forms, and
Note: No more than 60 calendar days may be authorized per treatment episode.
Member Absence from the Program
Absence of three calendar days or less:
Providers must request a modification to the current PA request by completing and submitting a new Mental Health Residential Treatment Services – Individuals Age 21-64 Prior Authorization Request Form found at: https://medicaid.utah.gov/forms. Ensure the following are completed:
Absence of more than three calendar days:
Providers must request a new non-clinical prior authorization by following the instructions in the ‘Non-Clinical PA Request’ section above. Ensure the following are completed:
Updated November 2022