38.3 Benefits and LimitationsPsychologists licensed by the Texas State Board of Examiners of Psychologists and enrolled as Medicaid providers are authorized to perform counseling and testing for mental illness/debility. Treatment does not include the practice of medicine. The services of a psychological associate (masters level psychologists), licensed chemical dependency counselor (LCDC), social worker, psychiatric nurse, or mental health worker are not covered by the Texas Medicaid Program and cannot be billed under a psychologist's provider identifier. Psychologists must not bill for services performed by people under their supervision. For mental health services, only the licensed psychologist and Medicaid-enrolled provider actually performing the service may bill the Texas Medicaid Program. Services provided by a licensed clinical social worker (LCSW), licensed professional counselor (LPC), or licensed marriage and family therapist (LMFT) are reimbursable directly to the LCSW, LPC, or LMFT. 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. Court-ordered behavioral health-billed services submitted with modifier H9 are excluded from the 12-hour limitation. 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. Claims submitted for psychological evaluation or testing performed by a qualified provider at the request of the Department of Family and Protective Services (DFPS), or by a court order, are not counted against the benefit limitations. These claims must be submitted with the following information:
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• 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 unable 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 10 encounters/visits per request and must be submitted on the Extended Outpatient Psychotherapy/Counseling Request Form. Requests must include the following:
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• Prior authorization is not granted to providers who have seen 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 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 treatments are mandated by the courts as 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 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 Texas Medicaid Program does not cover treatment for chronic diagnoses such as mental retardation and organic brain syndrome. Psychiatric daycare is not a covered service. Refer to: "Reimbursement" for more information about reimbursement methodologies. "Request for Extended Outpatient Psychotherapy/Counseling Form". "Licensed Clinical Social Worker (LCSW)" . "Licensed Professional Counselor (LPC)" . "Licensed Marriage and Family Therapist (LMFT)" for more information. |
The provider must submit the claim using modifier H9 with the procedure code(s) billed.
