CSHCN 2009 > Outpatient Behavioral Health > Benefits, Limitations, and Authorization Requirements

27.2 Benefits, Limitations, and Authorization Requirements

Outpatient mental health services are limited to no more than 30 encounters by all practitioners per eligible client per calendar year. Visits over the 30 encounter maximum for all mental health providers per client per calendar year are not a benefit of the CSHCN Services Program. The CSHCN Services Program will not provide outpatient behavioral health benefits for clients who are also eligible for Medicaid, the Texas Health Steps-Comprehensive Care Program (THSteps-CCP), or the Children's Health Insurance Program (CHIP). Coverage includes, but is not limited to, psychological testing, neuropsychological testing, psychotherapy, psychoanalysis, counseling, and narcosynthesis.

LCSWs, LMFTs, or LPCs may use procedure codes 90806, 90853, and 90847 when filing claims. LMFTs must use modifier U8.

Procedure codes 90801 or 90802 may be reimbursed once every 2 years to any provider. Subsequent visits should be billed using the psychotherapy procedure codes.

Psychiatrists and psychologists may use the following procedure codes when billing for exams and psychological services:

Psychiatrists alone may use the following procedure codes when filing claims:

Procedure codes 96101 and 96118 may be reimbursed up to 4 hours per day. Hours billed beyond 4 hours per day are denied.

If subsequent hospital visit codes 99231, 99232, or 99233 are billed on the same day by the same provider as procedure codes 90816 through 90829, the subsequent hospital visit codes are denied as part of another procedure.

Reimbursement is limited to a combined total of 12 hours of behavioral health services per day (group therapy services are handled on a retrospective basis). Reimbursement for each individual who is delegated to perform these services by a physician (MD or DO) is limited to a combined total of 12 hours of behavioral health services per day.

The CSHCN Services Program will not reimburse providers for visits over the 30 encounter maximum for all mental health providers per client per calendar year.