5.2 Services/Benefits, Limitations, and Prior AuthorizationPsychotherapy/counseling services that are provided by LCSWs, LMFTs, and LPCs are benefits of Texas Medicaid for clients of any age who are experiencing a significant behavioral health issue that is causing distress, dysfunction, or maladaptive functioning as a result of a confirmed or suspected psychiatric condition as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Psychotherapy /counseling services can be provided in the office (POS 1), home (POS 2), skilled nursing or intermediate care facility (SNF/ICF) (POS 4), outpatient hospital (POS 5), extended care facility (ECF) (POS 8), or in other locations (POS 9). LCSWs, LMFTs, and LPCs must not bill for services that were provided by people under their supervision, including services provided by students, interns, and licensed professionals. Services may only be billed to Texas Medicaid if they were provided by a licensed LCSW, LMFT, or LPC who is a Medicaid-enrolled practitioner. LCSWs, LMFTs, and LPCs who are employed by or remunerated by another provider may not bill Texas Medicaid directly for counseling services if that billing would result in duplicate payment for the same services. If more than one type of session is provided on the same date of service (outpatient individual, group, or family psychotherapy/counseling), each session type will be reimbursed individually. The only services that can be reimbursed are those provided to the Medicaid-eligible client per session. Services that are provided by a psychiatric nurse, mental health worker, psychiatric assistant, or psychological assistant (excluding a Masters-level licensed psychological associate [LPA]) are not covered by Texas Medicaid and cannot be billed under the provider identifier of any other outpatient behavioral health provider. Documentation of the face-to-face time with the client must be maintained in the client's medical record to support the procedure code billed. All entries must be documented clearly, be legible to individuals other than the author, and be dated (month/date/year) and signed by the performing provider. Documentation must include the following:
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• All payments are subject to recoupment if the required documentation is not maintained in the client's medical record. Family psychotherapy/counseling is reimbursed for only one Medicaid eligible client per session, regardless of the number of family members present during that session. When providing family counseling services, the Texas Medicaid client and a family member must be present during the face-to-face encounter/visit. 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 the 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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• Behavioral health services are limited to a total of 4 hours per client per day, regardless of the provider. 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 any/all behavioral health services (such as examinations, therapy, psychological or neuropsychological testing) by any provider, in the office, outpatient hospital, nursing home, or home settings. This limitation includes encounters/visits by all behavioral health practitioners. Each individual practitioner is limited to performing a combined total of 12 hours of behavioral health services per day. Claims submitted with a prior authorization number are not exempt from the 12-hour limitation. HHSC and TMHP routinely perform retrospective review of all providers. Retrospective review may include all behavioral health procedure codes included in the 12-hour system limitation. Behavioral health services subject to the 12-hour system limitation and retrospective review will be based on the provider's Texas Provider Identifier (TPI) base (the first seven digits of the TPI). The location where the services occurred will not be 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 TPI base, all services identified for restriction to the provider 12-hour limit will be counted regardless of whether they were performed at different locations. Refer to: Subsection 7.3, "The 12-Hour System Limitation" of this handbook for details about the 12-hours-per-day behavioral health services limitation. LCSWs, LMFTs, and LPCs must bill therapy/counseling services with procedure code 90804, 90806, 90808, 90847, or 90853. Note: LMFTs must use modifier U8 when billing these procedure codes. Psychotherapy/counseling services (procedure codes 90804, 90806, 90808, 90847, and 90853) must be submitted with one of the following diagnosis codes:
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The times at which the session began and ended
