28.3 Benefits and LimitationsLCSW counseling services are a benefit for clients suffering from a mental, psychoneurotic, or personality disorder, when performed in the office (place of service [POS] 1), home (POS 2), skilled nursing facility (SNF) (POS 4), outpatient hospital (POS 5), nursing facility (POS 8), or other location (POS 9). When billing for contracted LCSW counseling services provided to Texas Medicaid Program clients who are 20 years of age and younger and reside in a residential treatment facility, providers should use POS 9 (other location). LCSWs must not bill for services provided by people under their supervision; only the licensed LCSW and Medicaid enrolled practitioner providing the service may bill the Texas Medicaid Program. LCSWs who are employed by or remunerated by another provider may not bill the Texas Medicaid Program directly for counseling services if that billing would result in duplicate payment for the same services. Procedure codes 1-90806, 1-90847, and 1-90853 are allowable for services provided by an LCSW on an hourly basis. When billing or providing family counseling services (1-90847), note the following requirements for Medicaid reimbursement:
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• According to the definition of "family" provided by HHSC Household Determination Guidelines, only specific relatives are allowed to participate in family counseling services. These guidelines also address the roles of relatives in supervision and care of children with Temporary Assistance for Needy Families (TANF). The following specific relatives are included in family counseling services:
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• When billing for family, group, or individual counseling services, the time spent with the client must be reflected on the claim form as follows:
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• The time indicated on the claim form must be the time actually spent with the client. Each individual practitioner is limited to performing a combined total of 12 hours of behavioral health services per day. The claims processing system enforces the 12-hour system limitation for the following providers: advanced practice nurse (APN), PA, LMFT, LCSW, Psychologist, and LPC. Since physicians (doctor of medicine [MD] and doctors of osteopathy [DO]) can delegate and may possibly submit claims in excess of 12 hours in a given day, the claims system does not limit these providers to 12 hours per day. However physicians (MD and DO) and those to whom they delegate are still subject to the 12-hour limitation. Additionally providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day due to the manner in which group therapy is billed. Retrospective review may occur for both the total hours of services performed per day and the total hours of services billed per day. If inappropriate payments are identified, the reimbursement is recouped. In addition, all behavioral health procedure codes, whether or not they are currently included in the 12-hour system limitation, are subject to retrospective review and possible recoupment for all providers who deliver health services. Note: Documentation requirements for all services billed are listed for each individual specialty in this manual. The claims subject to the 12-hour provider limit are based on the provider identifier number submitted on the claim. The location where the services occur is not a basis for exclusion of hours. If a provider practices at multiple locations and has a different suffix for the various locations, but has the same provider identifier, all services identified for restriction to the provider's 12-hour limit are counted regardless of whether they were performed at different locations. Claims submitted with a prior authorization number are not exempt from the 12-hour limitation. The following table lists the behavioral health procedure codes included in the system limitation and shows the type of service/procedure code combinations, along with the time increments the system applies based on the billed procedure code. The time increments applied are used to calculate the 12-hour per day limitation.
If a cutback occurs for procedure codes included in the system limitation, the quantity allowed per service session designated is rounded up to one decimal point or rounded down to one decimal point following standard rounding procedures (as shown in the following example):
Formula Applied For client L on the table below, 80 billed minutes are applied, but the provider only has 40 available minutes before reaching the 12-hour daily limit (720 minutes); therefore, only 40 minutes are considered for reimbursement. The 40 allowed minutes are divided into the 80 applied minutes to get an allowed unit of .5 for payment.
Reminder: The procedure codes listed above have time ranges built in so the quantity billed should be reflected in quantities of one versus the actual amount of time spent with the client, i.e., procedure code 90804 is for 20 to 30 minutes of time spent with the client. The provider would bill a quantity of one when submitting a claim. If a claim is adjusted and causes additional minutes to be available to the provider for that day, the system does not automatically reprocess any previously denied or cutback claims that would now be payable. It is up to the provider to request reprocessing of the denied or cutback claims. Outpatient behavioral health services are limited to 30 encounters/visits per client, per calendar year (January 1 through December 31) regardless of provider, unless prior authorized. This limitation includes encounters/visits by all practitioners. School Health and Related Services (SHARS) behavioral rehabilitation services, MHMR services, laboratory, radiology, and medication monitoring services are not counted toward the 30-encounter/visit limitation. An encounter/visit is defined as each hour of therapy, psychological, and/or neuropsychological testing rendered per hour, per provider. Each Medicaid client is limited to 30 encounters/visits per calendar year. It is anticipated that this limitation, which allows for six months of weekly therapy or 12 months of biweekly therapy, is adequate for 75 to 80 percent of clients. Clinicians should plan therapy with this limit in mind. However, it may be medically necessary for some clients to receive extended encounters/visits. In these situations, prior authorization is required. A provider who sees a client regularly and anticipates that the client will require encounters/visits beyond the 30-encounter/visit limit must submit the request for prior authorization before the client's 25th encounter/visit. It is recognized that a client may change providers in the middle of the year, and the new provider may not be able to obtain complete information on the client. In these instances, prior authorization may be made before rendering services when the request is accompanied by an explanation as to why the provider was not able to submit the prior authorization request by the client's 25th encounter/visit. All authorization requests for extension of outpatient psychotherapy sessions beyond the annual 30-encounter/visit limitation are limited to ten encounters/visits per request and must be submitted on the Extended Outpatient/Counseling Request Form. Requests must include the following:
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• All areas of request must be completed with the information required by the form. If additional room is needed providers may state "see attached," but the attachment must contain the specific information required in that section of the form. Refer to: "Request for Extended Outpatient Psychotherapy/Counseling Form" Prior authorization is not granted to providers who have been seeing a client for an extended period of time or from the start of the calendar year and who have not requested prior authorization before the 25th encounter/visit. It is recommended that a request for extension of outpatient behavioral health services be submitted no sooner than 30 days before the date of service being requested, so that the most current information is provided. The number of encounters/visits authorized is dependent on the client's symptoms and response to past treatment. If the client requires additional extensions, the provider must submit a new request for prior authorization at the end of each extension period. The request for additional encounters/visits must include new documentation addressing the client's current condition, treatment plan, and the therapist's rationale supporting the medical necessity for these additional encounters/visits. Prior authorization for an extension of outpatient behavioral health services is granted when the treatment is mandated by the courts as a court-ordered service. A copy of the court order for outpatient treatment signed by the judge must accompany prior authorization requests. Mail or fax the request to the following address:
Texas Medicaid & Healthcare Partnership Providers can submit requests for extended outpatient psychotherapy/counseling through the TMHP website. Refer to: "Prior Authorization Requests Through the TMHP Website" for additional information, including mandatory documentation requirements and retention. The following services are not covered by the Texas Medicaid Program (except where specifically indicated in other sections):
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• Refer to: "Managed Care" for more information, or contact the client's BHO. Do not bill TMHP for services rendered to NorthSTAR clients. |
The client must be present when family counseling services are provided.
