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2.3 Services/Benefits, Limitations, and Prior Authorization
2.3.1 Outpatient Counseling
CDTF services must be determined by a qualified credentialed counselor (QCC) (as defined by DSHS licensure standards) to be reasonable and necessary for a person who has a diagnosis of substance abuse or dependence. Substance abuse or dependence is based on the diagnostic criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Chemical dependency is defined as meeting at least three of the diagnostic criteria for psychoactive substance dependence in the current edition of the DSM.
CDTF services must be billed with the appropriate International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code. Providers must consider the appropriate DSM diagnosis for the client's condition and determine the comparable covered ICD-9-CM diagnosis code.
Sufficient documentation must be maintained in the client's medical record to support the diagnosis and justify the decision for placement into the program.
Services for caffeine or nicotine withdrawal are not benefits of Texas Medicaid.
CDTF services are limited to clients 20 years of age or younger. DSHS limits CDTF programs as follows:
• Under the CDTF adolescent programs, Texas Medicaid coverage for outpatient counseling services for substance abuse or dependence is limited to clients who are 13 through 17 years of age. However, young adults who are 18 through 20 years of age may receive services under the adolescent program when the screening process indicates the individual's needs, experiences, and behavior are similar to those of adolescent clients.
•Under the CDTF adult programs, Texas Medicaid coverage for outpatient counseling services for substance abuse or dependence is limited to clients who are 18 through 20 years of age. However, adolescents who are 17 years of age may receive services under the adult programs when they are referred by the adult criminal justice system, or when the screening process indicates the individual's needs, experiences, and behavior are similar to those of adult clients.
•Every exception to the general age requirements must be clinically justified and documented in writing by a QCC. The facility must maintain the supporting documentation, including the QCC admission approval, in the client's medical record.
The following procedure code and modifier combinations must be used for CDTF outpatient counseling services provided by a QCC:
•H0004 with modifier HF (identifies individual counseling services provided in 15-minute increments)
•H0005 with modifier HF (identifies group counseling services provided in 1-hour increments)
Note: Modifier HF identifies services in a substance abuse program.
CDTF outpatient group counseling for substance abuse or dependence is limited to 135 hours, per client, per calendar year (January 1 through December 31).
CDTF outpatient individual counseling for substance abuse or dependence is limited to 26 hours per client, per calendar year.
Outpatient group and individual counseling is only payable in the outpatient setting.
Clients in an inpatient status are not eligible for CDTF outpatient services.
CDTF outpatient counseling services do not include chemical dependency education, life skills training, assessments, or prevention services.
Clients in a residential chemical dependency treatment facility are not eligible for CDTF outpatient services.
CDTF outpatient counseling services must be submitted with one of the following diagnosis codes to be considered for reimbursement:
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