TMPPM 2008 > Texas Medicaid Services > Physician > Procedures and Services

36.4.39 Psychiatric Services

Each individual practitioner is limited to performing a combined total of 12 hours of behavioral health services per day. The claims processing system will enforce the 12-hour system limitation for the following providers: APN, PA, LMFT, LCSW, psychologist, and LPC. Since physicians (MD and DO) can delegate and may possibly submit claims in excess of 12 hours in a given day, the claims system will 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. Providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day because of 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 will be recouped.

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 will be based on the provider identifier submitted on the claim. The location in which the services occur will not be a basis for the 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 will be counted regardless of whether they were performed at different locations.

Court-ordered behavioral health services submitted with modifier H9 will be excluded from the 12-hour limitation.

Claims submitted with a prior authorization number will not be exempt from the 12-hour limitation.

The following table lists the behavioral health procedure codes that are included in the system limitation and shows the TOS and procedure code combinations and the time increments that the system will apply based on the billed procedure code.

The time increments applied will be 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 will be rounded up to one decimal point or rounded down to one decimal point following standard rounding procedures.

For 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 that 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 the adjustment causes additional minutes to be available to the provider for that day, the system will not automatically reprocess any previously denied or cutback claims that would now be payable. It will be up to the provider to request reprocessing of the denied or cutback claims.

Claims submitted for psychological evaluation or for testing performed by a qualified provider at the request of the Department of Family and Protective Services (DFPS) or by court order will not be counted against the benefit limitations. These claims must be submitted with the following information:

•The provider must submit the claim with the procedure codes and modifier H9.

•If psychological services are court-ordered, the claim must include a copy of the court order for outpatient treatment that was signed by the judge and documentation of medical necessity.

•If psychological services are directed by DFPS, the claim must include the name and telephone number of the DFPS employee who gave the direction, the reason for the DFPS request, and documentation of medical necessity.

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, mental health mental retardation (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.

If a provider determines that additional services are medically necessary within the calendar year, prior authorization must be obtained before providing the 25th service.

Note: Psychiatrists and psychologists in the Dallas service area must be enrolled as a network provider in the NorthSTAR BHO network to provide services to NorthSTAR clients. NorthSTAR is a managed care program in the Dallas service area that covers behavioral health services. Physicians that provide behavioral health services to clients in NorthSTAR must be a network provider of the NorthSTAR BHO to provide services to NorthSTAR clients.

It is anticipated that this limitation, which allows for 6 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. This request for prior authorization helps ensure the client does not miss any necessary encounters/visits with the mental health provider by having prior authorization in place before providing the 25th service. It will also assist the provider with timely and accurate claims payment.

It is recognized that sometimes 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. This information must be submitted in addition to the usual medical necessity information required with every request.

Prior authorization will not be 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 be submitted no sooner than 30 days prior to the date of service being requested, so that the most current information is provided.

All authorization requests for extension of outpatient psychotherapy sessions beyond the annual 30-encounter limitation are limited to 10 encounters/visits per request and must be submitted on the Request for Extended Outpatient Psychotherapy/Counseling Form. Requests must include the following:

•Client name and Medicaid number.

•Provider name and provider identifier.

•Clinical update, including current specific symptoms and response to past treatment, and treatment plan (measurable short term goals for the extension, specific therapeutic interventions to be used in therapy, measurable expected outcomes of therapy, length of treatment anticipated and planned frequency of encounters/visits).

•Number, TOSs requested, and the dates based on the frequency of encounters/visits that the services will be provided.

•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.

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 for court-ordered services. 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
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1-512-514-4213

Providers can submit requests for extended outpatient psychotherapy/counseling on the TMHP website.

Refer to: "Prior Authorization Requests Through the TMHP Website" for additional information to include mandatory documentation requirements and retention.

Treatment for chronic diagnosis codes such as mental retardation are not covered by Medicaid.

Psychological testing (5-96101) and neuropsychological testing (1-96118) are covered services for the following diagnosis codes only:

If separate charges for an office visit and psychological testing or psychotherapy are billed on the same day, the office visit is denied as part of another procedure on the same day unless the diagnosis referenced to the office visit indicates a physical condition unrelated to the psychiatric diagnosis. In this instance the office visit is paid separately.

Report psychotherapy of less than 20 minutes duration using the appropriate E/M code.

Procedure codes 1-90801 and 1-90802 are limited to once per day per client, any provider, regardless of the number of professionals involved in the interview, and once per year per provider (same provider) in any setting.

An interactive interview (1-90802) may be covered to the extent it is medically necessary. Examples of medical necessity include, but are not limited to, clients whose ability to communicate is impaired by an expressive or receptive language impairment from various causes, such as conductive or sensorineural hearing loss, deaf mutism, or aphasia.

A diagnostic interview (1-90801, 1-90802) may be incorporated into an E/M service provided the required elements of the E/M service are fulfilled. A diagnostic interview (1-90801 or 1-90802) will be denied as part of any E/M service when billed for the same date of service by the same provider.

Procedure code 1-90802 billed on the same day as 1-90801 by the same provider is denied as part of another procedure billed on the same day.

If procedure code 1-90801 or 1-90802 is billed, the following psychiatric therapeutic procedure codes performed the same day by the same provider are denied as part of the initial psychiatric exam.

If procedure code 1-90801 or 1-90802 is billed on the same day as 1-99221, 1-99222, and 1-99223 by the same provider, the initial hospital visit is denied as part of another procedure on the same day.

Documentation for diagnostic interview examinations (1-90801, 1-90802) must include:

•Reason for referral/presenting problem.

•Prior History, including prior treatment.

•Other pertinent medical, social, and family history.

•Clinical observations and mental status examinations.

•Complete Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis.

•Recommendations, including expected long term and short term benefits.

•For the interactive diagnostic interview (1-90802), the medical record must indicate the adaptations utilized in the session and the rationale for employing these interactive techniques.

Outpatient psychotherapy (1-90847, 1-90853, 1-90857, and 1-90804) billed on the same date of service as narcosynthesis (1-90865) will be denied.

If the following psychotherapy or psychoanalysis codes are billed on the same day as a subsequent hospital visit (1-99231, 1-99232, 1-99233, 1-99238, and 1-99239) by the same provider, the subsequent hospital visit is denied as part of another procedure billed on the same day.

A hospital visit subsequent care (1-99231, 1-99232, 1-99233, 1-99238, and 1-99239) may be considered for reimbursement on the same day as ECT. Hospital subsequent care for diagnoses unrelated to the ECT will be considered on appeal.

Psychotherapy (with and without E/M) is coded by the following:

Psychoanalysis should be coded 1-90845.

If the following psychotherapy procedure codes are billed on the same day as psychoanalysis (1-90845), psychotherapy is denied.

The following psychiatric services are not covered by the Texas Medicaid Program:

•Adult and individual activities.

•Biofeedback.

•Daycare.

•Hypnosis.

•Intensive outpatient program services.

•Marriage counseling.

•Music or dance therapy.

•Psychiatric day treatment program services.

•Psychiatric services for chronic diagnoses such as mental retardation.

•Recreational therapy.

•Services provided by a licensed chemical dependency counselor (LCDC), psychiatric nurse (RN or licensed vocational nurse [LVN]), mental health worker, or psychological associate.

•Thermogenic therapy.

Medicare deductibles or coinsurance for inpatient stays in psychiatric hospitals are not payable for clients 22 to 64 years of age. This limitation does not apply to psychiatric services rendered in a general acute care hospital.

Procedure codes 1-90846 and 1-90849 are not reimbursed by the Texas Medicaid Program.

When billing or providing family therapy/counseling services, note the following requirements for Medicaid reimbursement:

•The client must be present when family therapy/counseling services are provided.

•Family therapy/counseling is reimbursable only for one family member per session.

According to the definition of family provided by DADS 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 Temporary Assistance to Needy Families (formerly Aid to Families with Dependent Children [AFDC]) children. The following specific relatives are included in family counseling services:

•Father or mother.

•Grandfather or grandmother.

•Brother or sister.

•Uncle, aunt, nephew, or niece.

•First cousin or first cousin once removed.

•Stepfather, stepmother, stepbrother, or stepsister.

When individual, group, or family psychotherapy is billed by any provider on the same day, each type of session is paid. When multiples of each type of session are billed, the most inclusive code from each type of session is paid and the others are denied.

Refer to: "Request for Extended Outpatient Psychotherapy/Counseling Form".