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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.8 Health and Behavior Assessment and Intervention

2.8
2.8.1
Health and Behavior Assessment and Intervention (HBAI) services are a benefit of Texas Medicaid for clients who are 20 years of age and younger when the services are provided by a licensed practitioner of the healing arts (LPHA) who is co-located in the same office or building complex as the client’s primary care provider. These services are designed to identify the psychological, behavioral, emotional, cognitive and social factors important to prevention, treatment or management of physical health symptoms.
HBAI services are a benefit when the client meets all of the following criteria:
The client has a documented need for psychological evaluation or intervention to successfully manage his or her physical illness, and activities of daily living.
HBAI services that include the client’s family are a benefit when the family member directly participates in the overall care of the client.
Family is defined as a responsible adult. This adult individual has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to, biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage.
HBAI services may be reimbursed when billed with the following procedure codes:
 
These services may be rendered by physician, nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed marriage family therapist (LMFT), Comprehensive Care Program (CCP) social worker, or psychologist provider in the office or outpatient setting.
LMFTs must bill with state defined modifier U8 to identify services billed.
For services that are rendered by physician, NP, CNS, or PA providers, claims must be submitted with the appropriate evaluation and management (E/M) procedure codes (99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, or 99215). A primary care provider may bill the HBAI procedure codes for an LPHA that is in the PCP’s practice.
HBAI services are limited to four 15-minute units (one hour) per day, any procedure, any provider. A unit is defined as 15 minutes of in-person evaluation time. An in-person evaluation is defined as a patient evaluation conducted by a provider who is at the same physical location as the client. These services are considered acute per rolling 180 days from the initiation of services and are limited as shown in the following table:
 
Limited to a maximum of four 15-minute units (one hour) per client, per rolling 180 days, any provider
Limited to a maximum of four 15-minute units (one hour) per client, per rolling 180 days, any provider
Limited to a maximum of sixteen 15-minute units (four hours), per client, per rolling 180 days, any provider
Rural Health Clinics and Federally Qualified Health Centers may be reimbursed for client in-person evaluation visits based on encounter rates.
For re-assessment (procedure code 96151), providers must maintain documentation in the client’s medical record that details the change in the mental or medical status warranting reassessment of the client’s capacity to understand and cooperate with the medical interventions that are necessary to the client’s health and well-being.
Clients must be referred for psychiatric or psychological counseling as soon as the need is identified. Providers cannot use all 16 units if the need for psychiatric or psychological intervention is identified earlier.
After the initial assessment (procedure code 96150), if the client’s PCP learns that the client is receiving psychiatric or psychological services from another health-care provider, the PCP should contact the health-care provider to determine whether the client is already receiving any HBAI services. If HBAI services are not being provided, the PCP may consider referring the client for a more appropriate level of psychiatric or psychological treatment.
Refer to:
Subsection 6.4, “Outpatient Behavioral Health Services”in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks) for more information about psychological counseling services beyond the acute care limitations outlined in this section.
The initial clinical interview, reassessment, psychophysiological monitoring, observation, and intervention do not include the following:
After the initial 180 days of HBAI services, the client may receive another episode of HBAI with the same medical diagnosis if there is a newly identified behavioral health issue. The client may have two episodes of HBAI per rolling year.
HBAI services are adjunct to other services and are to be used as a non-intensive means to identify specific needs. As appropriate, the client should be referred for those additional services that would meet the client’s biopsychosocial needs.

Texas Medicaid & Healthcare Partnership
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