29.3 Benefits and LimitationsLMFT counseling services are a benefit for clients suffering from a mental, psychoneurotic, or personality disorder when provided in the office, (place of service [POS] 1), the home (POS 2), skilled nursing facility (SNF) (POS 4), outpatient hospital (POS 5), nursing facility (POS 8), or another location (POS 9). When billing for contracted LMFT counseling services provided to Texas Medicaid clients who are 20 years of age or younger and who reside in a residential treatment facility, providers should use POS 9 (other location). LMFTs must not bill for services provided by people under their supervision, including services provided by students, interns, or licensed professionals under their supervision. Only the licensed LMFT and Medicaid-enrolled practitioner providing the services may bill Medicaid. LMFTs employed or remunerated by another provider may not bill Medicaid directly for counseling service if the billing results in a duplicate payment for the same services. Procedure codes 90806, 90847, and 90853 are allowable for services provided by an LMFT on an hourly basis. When billing or providing family counseling services (procedure code 90847), note the following requirements for Medicaid reimbursement:
•
• According to the definition of "family" provided by the 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:
•
•
•
•
•
• When billing for family, group, or individual counseling services, the time spent with the client must be reflected on the claim form as follows:
•
•
•
• The time indicated on the claim form must be the time actually spent with the client. LMFTs must use modifier U8 to identify the provider of the service as an LMFT. 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. Refer to: "Benefits and Limitations" for details about the 12-hours-per-day behavioral health services limitation. 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, mental health/mental retardation (MHMR), laboratory, radiology, and medication monitoring services are not counted toward the 30-encounter/visit limitation. An encounter/visit is defined as each occurrence of therapy, psychological, and/or neuropsychological testing rendered per hour, per provider. Additionally, clients should receive no more than four hours of therapy per day. Each Medicaid client is limited to 30 encounters/visits per calendar year. 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. It is recognized that there are times when 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 10 encounters/visits per request and must be submitted on the Extended Outpatient/Counseling Request Form. Requests must include the following:
•
•
•
•
• All areas of request must be completed with the required information. 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 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:
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 Texas Medicaid (except where specifically indicated in other sections):
•
•
•
•
• |
The client must be present when family counseling services are provided.
