Behavioral Health and
Case Management Services
Handbook

 

1 General Information

The information in this handbook is intended for the Case Management for the Blind Children’s Vocational Discovery and Development Program (BCVDDP), Case Management for Children and Pregnant Women, and services provided by a licensed clinical social worker (LCSW), licensed marriage and family therapist (LMFT), licensed professional counselor (LPC), psychologist, physician, advanced practice registered nurse (APRN), physician assistant (PA), or providers of intellectual and develop­mental disability (IDD) case management, mental health targeted case management, and mental health rehabilitative services.

All providers are required to report suspected child abuse or neglect as outlined in subsection 1.6.1.2, “Reporting Child Abuse or Neglect” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) and subsection 1.6.1.5, “Training” in “Section 1: Provider Enrollment and Respon­sibilities” (Vol. 1, General Information).

Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure to deliver, at all times, health-care items and services to Medicaid clients in full accordance with all appli­cable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

“Appendix B: Vendor Drug Program” (Vol. 1, General Information) for information about outpatient prescription drugs and the Medicaid Vendor Drug Program.

1.1Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated timeframe of an inpatient hospital stay and are related to the inpatient hospital admission will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital.

These reimbursement guidelines do not apply in the following circumstances:

The professional services are rendered in the inpatient hospital setting.

The hospital and the physician office or other entity are both owned by a third party, such as a health system.

The hospital is not the sole or 100-percent owner of the entity.

Refer to:  Subsection 3.7.3.8, “Payment Window Reimbursement Guidelines” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional infor­mation about the payment window reimbursement guidelines.

2 Blind Children’s Vocational Discovery and Development Program (BCVDDP)

2.1Overview

BCVDDP services are provided to help children who are blind and visually impaired to develop their individual potential. This program offers a wide range of services that are tailored to each child and their family’s needs and circumstances. By working directly with the entire family, this program can help children develop the concepts and skills needed to realize their full potential.

BCVDDP services include the following:

Assisting the client in developing the confidence and competence needed to be an active part of their community

Providing support and training to children in understanding their rights and responsibilities throughout the educational process

Assisting family and children in the vocational discovery and development process

Providing training in areas like food preparation, money management, recreational activities, and grooming

Supplying information to families about additional resources

2.2Enrollment

The Department of Assistive and Rehabilitative Services (DARS) Division for Blind Services (DBS) is the Medicaid provider of case management for clients who are 21 years of age and younger and blind or visually impaired. Providers must meet educational and work experience requirements that are commensurate with their job responsibilities and must be trained in DBS case management activities.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about procedures for enrolling as a Medicaid provider.

2.3Services, Benefits, Limitations, and Prior Authorization

Services eligible for reimbursement are limited to one contact per month, per client, regardless of the number of contacts that are made during the month. DARS DBS providers should bill procedure code G9012.

A contact is defined as “an activity performed by a case manager with the client or with another person or organization on behalf of the client to locate, coordinate, and monitor necessary services.”

Refer to:  Subsection A.8, “Department of Assistive and Rehabilitative Services (DARS), Blind Services” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

2.3.1Prior Authorization

Prior authorization is not required for BCVDDP case management services.

2.4Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including BCVDDP services.

BCVDDP services are subject to retrospective review and recoupment if documentation does not support the service billed.

2.5Claims Filing and Reimbursement

BCVDDP case management services must be submitted to the Texas Medicaid & Healthcare Partnership (TMHP) in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills or itemized state­ments are not accepted as claim supplements. Providers must not submit a claim when or after the client turns 21 years of age.

Claims may be submitted up to 365 days from the date of service in accordance with 1 TAC §354.1003.

Any child who has a suspected or diagnosed visual impairment may be referred to BCVDDP. DARS DBS assesses the impact the visual impairment has on the child’s development and provides blindness-specific services to increase the child’s skill level in the areas of independent living, communication, mobility, social, recreational, and vocational discovery and development. For more information, visit the DARS website at www.dars.state.tx.us.

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 2.9, “Federal Medical Assistance Percentage (FMAP)” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for federal matching percentage.

3 Case Management for Children and Pregnant Women

3.1Overview

Case management services are provided to help eligible clients gain access to necessary medical, social, educational, and other services. Case managers assess a client’s need for these services and then develop a service plan to address those needs.

3.1.1Eligibility

To be eligible for services, a person must:

Be eligible for Texas Medicaid.

Be a pregnant woman who has a high-risk condition or a child (birth through 20 years of age) who has a health condition or health risk.

Need assistance in gaining access to necessary medical, social, educational and other services related to their health condition, health risk, or high-risk condition.

Want to receive case management services.

Pregnant women who have a high-risk condition are defined as those who have a medical or psycho­social condition that places them and their fetuses at a greater than average risk for complications, either during pregnancy, delivery, or following birth. Children with a health condition are defined as children who have a health condition or health risk or children who have or are at risk for a medical condition, illness, injury, or disability that results in the limitation of function, activities, or social roles in comparison with healthy same-age peers in the general areas of physical, cognitive, emotional, or social growth and development.

3.1.2Referral Process

To refer a Medicaid client for Case Management for Children and Pregnant Women services, providers may do one of the following:

Visit www.dshs.texas.gov/caseman/Make-a-Referral-to-Case-Management/.shtm to obtain a referral form.

Call THSteps toll free at 1-877-847-8377 from 8 a.m. to 8 p.m., Central Time, Monday through Friday.

Contact a Case Management for Children and Pregnant Women provider directly at www.dshs.texas.gov/caseman/providerRegion.shtm. A case management provider will contact the family to offer a choice of providers and obtain information necessary to request prior authorization for case management services.

A referral for Case Management for Children and Pregnant Women services can be received from any source.

3.2Enrollment

Enrollment for Case Management for Children and Pregnant Women providers is a two-step process.

Step 1

Potential providers must submit a Health and Human Services Commission (HHSC) Case Management for Children and Pregnant Women provider application to the HHSC Health Screening and Case Management Unit.

Both registered nurses who have an associate’s, bachelor’s, or advanced degree and social workers who have a bachelor’s or advanced degree are eligible to become case managers if they are currently licensed by their respective Texas licensure boards and the license is not temporary in nature. Registered nurses with associate degrees must also have at least two years of cumulative, paid, full-time work experience or two years of supervised full-time, educational, internship/practicum experience in the past ten years. The experience must be with pregnant women or with children who are 20 years of age and younger. The experience must include assessing psychosocial and health needs and making community referrals for these populations. Registered nurses with bachelor or advance degrees and social workers do not have to meet any experience requirements.

For more information about provider qualifications and enrollment, contact HHSC at 1-512-458-7111, ext. 2168, visit the case management website at www.dshs.texas.gov/caseman/default.shtm, or write to the following address:

Health and Human Services Commission
Case Management for Children and Pregnant Women
PO Box 149347, MC 1938
Austin, TX 78714-9347

Note:Before providing services, each case manager must attend HHSC case manager training. Training is conducted by DSHS regional staff.

Step 2

Upon approval by HHSC, potential providers must enroll as a Medicaid provider for Case Management for Children and Pregnant Women and submit a copy of their HHSC approval letter. Facility providers must enroll as a Case Management for Children and Pregnant Women group, and each eligible case manager must enroll as a performing provider for the group. Federally Qualified Health Center (FQHC) facilities that provide Case Management for Children and Pregnant Women services will use their FQHC number and should not apply for an additional provider number for Case Management for Children and Pregnant Women.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about the procedures for enrolling as a Medicaid provider.

3.3Services, Benefits, Limitations, and Prior Authorization

Case Management for Children and Pregnant Women services are limited to one contact per day per client. Additional provider contacts on the same day are denied as part of another service rendered on the same day.

Procedure code G9012 is to be used for all Case Management for Children and Pregnant Women services. Modifiers are used to identify which service component is provided.

Service

Contact Code

Comprehensive visit

G9012 with modifier U5 and modifier U2

Follow-up face-to-face

G9012 with modifier U5 and modifier TS

Follow-up telephone

G9012 with modifier TS

Providers must adhere to Case Management for Children and Pregnant Women program rules, policies, and procedures.

Note:Case Management for Children and Pregnant Women providers are not required to file claims with other health insurance before filing with Medicaid.

Reminder:Billable services are defined in program rule 25 TAC §27.11.

Case Management for Children and Pregnant Women services are not billable when a client is an inpatient at a hospital or other treatment facility.

Reimbursement will be denied for services rendered by providers who have not been approved by HHSC.

3.3.1Prior Authorization

All services must be prior authorized. One comprehensive visit is approved for all eligible clients. Follow-up visits are authorized based on contributing factors. Additional visits can be requested and may be authorized based on a continuing need for services. A prior authorization number is required on all claims for Case Management for Children and Pregnant Women services.

Note:Prior authorization is a condition of reimbursement, not a guarantee of payment.

Approved case management providers may submit requests for prior authorization from HHSC on the Department of State Health Services (DSHS) website at www.dshs.texas.gov/caseman/subpaweb.shtm.

3.4Technical Assistance

Providers may contact HHSC program staff as needed for assistance with program concerns. Providers should contact TMHP provider relations staff as needed for assistance with claims problems or concerns.

3.4.1Assistance with Program Concerns

Providers who have questions, concerns, or problems with program rule, policy, or procedure may contact HHSC program staff. Contact names and numbers can be obtained from the case management website at www.dshs.texas.gov/caseman/contact4.shtm, or by calling 1-512-458-7111, Ext. 2168.

Regional DSHS staff make routine contact with providers to ensure providers are delivering services as required.

3.5Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including Case Management for Children and Pregnant Women services.

Case Management for Children and Pregnant Women services are subject to retrospective review and recoupment if documentation does not support the service billed.

3.6Claims Filing and Reimbursement

3.6.1Claims Information

Case Management for Children and Pregnant Women services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized state­ments, are not accepted as claim supplements.

Case Management for Children and Pregnant Women providers are reimbursed in accordance with 1 TAC §355.8401. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

3.6.2Managed Care Clients

Case Management for Children and Pregnant Women services are carved out of Medicaid managed care and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid managed care clients, but are administered by TMHP and not the client’s managed care organization (MCO).

4 Outpatient Mental Health Services

Outpatient mental health services are used for the treatment of mental illness and emotional distur­bances in which the clinician establishes a professional contract with the client and, utilizing therapeutic interventions, attempts to alleviate the symptoms of mental illness or emotional disturbance, and reverse, change, or ameliorate maladaptive patterns of behavior.

Outpatient mental health services include psychiatric diagnostic evaluation, psychotherapy (including individual, group, or family psychotherapy), psychological, neurobehavioral, or neuropsychological testing, pharmacological management services, and electroconvulsive therapy (ECT).

Outpatient mental health services are benefits of Texas Medicaid when provided to clients who are experiencing a mental health issue that is causing distress, dysfunction, and/or maladaptive functioning as a result of a confirmed or suspected psychiatric condition as defined in the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

Note:Claims will require the corresponding diagnosis code(s) from the current edition of the Inter­national Classification of Diseases (ICD).

4.1Provider Enrollment

Mental health service providers include physicians, PAs, APRNs, LCSWs, LMFTs, LPCs, psychologists, licensed psychological associates (LPAs), provisionally licensed psychologists (PLPs), post-doctoral fellows, and pre-doctoral psychology interns.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about procedures for enrolling as a Medicaid provider.

4.1.1Physicians

To enroll in Texas Medicaid to provide medical services, physicians (doctor of medicine [MD] or doctor of osteopathy [DO]) and doctors (doctor of dental medicine [DMD], doctor of dental surgery [DDS], doctor of optometry [OD], and doctor of podiatric medicine) must be authorized by the licensing authority of their profession to practice in the state where the services are performed at the time they are provided.

Providers cannot be enrolled in Texas Medicaid if their licenses are due to expire within 30 days. A current Texas license must be submitted.

All physicians except gynecologists, pediatricians, pediatric subspecialists, pediatric psychiatrists, and providers performing only THSteps medical or dental checkups must be enrolled in Medicare before enrolling in Medicaid. TMHP may waive the Medicare enrollment prerequisite for pediatricians or physicians whose type of practice and service may never be billed to Medicare.

4.1.2Physician Assistants (PAs)

To enroll in Texas Medicaid, a PA must be licensed as a PA and be recognized as a PA by the Texas Physician Assistant Board. All PAs are enrolled within the categories of practice as determined by the Texas Medicaid Board. PAs can enroll as an individual, group, or as a performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required.

4.1.3Advanced Practice Registered Nurses (APRNs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, a nurse practitioner (NP) or clinical nurse specialist (CNS) recognized as an APRN must be licensed by the Texas Board of Nursing (TBON). NP/CNSs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based NP/CNSs is enrolling as part of a Medicare-enrolled group, then the NP/CNSs must also be enrolled in Medicare.

Providers that hold a temporary license are not eligible to enroll in Medicaid. NP/CNSs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.4Licensed Clinical Social Workers (LCSWs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LCSW must be licensed by the Texas State Board of Social Worker Examiners. LCSWs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LCSW is enrolling as part of a Medicare-enrolled group, then the LCSW must also be enrolled in Medicare.

Providers that hold a temporary license are not eligible to enroll in Medicaid. LCSWs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.5Licensed Marriage and Family Therapists (LMFTs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LMFT must be licensed by the Texas State Board of Examiners of Licensed Marriage and Family Therapists. LMFTs are covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement. LMFTs can enroll as part of a clinic/group practice whether or not they are enrolled in Medicare. Providers that hold a temporary license are not eligible to enroll in Medicaid. LMFTs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.6Licensed Professional Counselors (LPCs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LPC must be licensed by the Texas Board of Examiners of Professional Counselors. LPCs are covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement. LPCs can enroll as part of a clinic/group practice whether or not they are enrolled in Medicare. Providers that hold a temporary license are not eligible to enroll in Medicaid. LPCs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.7Psychologists

To enroll in Texas Medicaid, whether as an individual or as part of a group, a psychologist must be licensed by the Texas State Board of Examiners of Psychologists (TSBEP). Psychologists must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based psychologist is enrolling as part of a Medicare-enrolled group, then the psychologist must also be enrolled in Medicare. Psychologists cannot be enrolled if they have a license that is due to expire within 30 days. A current license must be submitted. Texas Medicaid accepts temporary licenses for psychologists.

4.1.8Licensed Psychological Associates (LPAs)

LPAs must be licensed by TSBEP. LPAs are expected to abide by their scope and standards of practice.

Services performed by an LPA are a Medicaid-covered benefit when the following conditions are met:

The services must be performed under the direct supervision of a licensed, Medicaid-enrolled psychologist.

The supervising psychologist must be in the same office, building, or facility when the service is provided and must be immediately available to furnish assistance and direction.

The LPA performing the service must be an employee of either the licensed psychologist or the legal entity that employs the licensed psychologist.

The TSBEP requires an LPA to work under the direct supervision of a licensed psychologist and does not allow an LPA to engage in independent practice. Therefore, an LPA will not be independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s provider identifier.

Psychological services provided by an LPA must be billed under the supervising psychologist’s Medicaid identifier or the Medicaid identifier of the legal entity employing the supervising psychologist.

4.1.9Provisionally Licensed Psychologists (PLPs)

PLPs must be licensed by TSBEP. A PLP may perform all of the services that are benefits of Texas Medicaid when the services are performed by a psychologist.

PLPs are expected to abide by their scope and standards of practice. Services performed by a PLP are a Medicaid-covered benefit when the following conditions are met:

The services must be performed under the direct supervision of a licensed psychologist in accor­dance with the TSBEP guidelines.

The supervising psychologist must be in the same office, building, or facility when the service is provided and must be immediately available to furnish assistance and direction.

The PLP who is performing the service must be an employee of either the licensed psychologist or the legal entity that employs the licensed psychologist.

The TSBEP requires a PLP to work under the direct supervision of a licensed psychologist and does not allow a PLP to engage in independent practice. Therefore, a PLP will not be independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s provider identifier.

Psychological services provided by a PLP must be billed under the supervising psychologist’s Medicaid identifier or the Medicaid identifier of the legal entity employing the supervising psychologist.

4.1.10Post-Doctoral Fellows

Post-doctoral psychology fellows who satisfy the provisional licensure examination requirements but have not yet been awarded the PLP designation are eligible to perform delegated psychological services within their scope of practice and under the direct supervision of a licensed psychologist.

Psychology interns are not independently enrolled in Texas Medicaid; therefore, they do not have a provider identifier.

Psychological services provided by an intern must be billed under the supervising psychologist’s Medicaid identifier or the Medicaid identifier of the legal entity employing the supervising psychologist.

4.1.11Pre-doctoral Psychology Interns

Pre-doctoral psychology interns who are participating in a pre-doctoral psychology internship at a site that is a member of the Association of Psychology Postdoctoral and Internship Centers (APPIC) are eligible to perform delegated psychological services within their scope of practice and under the direct supervision of a licensed psychologist.

Psychology interns are not independently enrolled in Texas Medicaid; therefore, they do not have a provider identifier.

4.2* Services, Benefits, Limitations

The following procedure codes may be reimbursed for outpatient mental health services:

Procedure codes

90791

90792

90832

90833

90834

90836

90837

90838

90846

90847

90853

90870

90899

96101

96116

96118

The following psychotherapy procedure codes are limited to 30 visits per calendar year. Additional services require prior authorization:

Procedure codes

90832

90833*

90834

90836*

90837

90838*

90846

90847

90853

*Add-on procedure code must be billed with the appropriate E/M code

The following add-on procedure codes may be used for prolonged psychotherapy services:

Procedure codes

99354

99355

Procedure codes 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853 are limited to the following diagnosis codes:

Diagnosis Codes

F0390

F0391

F04

F05

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0781

F0789

F09

F1010

F1011

F10120

F10121

F1014

F10150

F10151

F10159

F10180

F10181

F10182

F10188

F1019

F1020

F1021

F10220

F10221

F10230

F10231

F10232

F10239

F1024

F10250

F10251

F10259

F1026

F1027

F10280

F10281

F10282

F10288

F1029

F10921

F1094

F10950

F10951

F10959

F1096

F10980

F10981

F10982

F10988

F1099

F1110

F1111

F11120

F11121

F11122

F11129

F1114

F11150

F11151

F11159

F11181

F11182

F11188

F1119

F1120.

F1121

F11220

F11221

F11222

F11229

F1123

F1124

F11250

F11251

F11259

F11281

F11282

F11288

F1129

F11920

F11921

F11922

F11929

F1193

F1194

F11950

F11951

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12121

F12122

F12129

F12150

F12151

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12221

F12222

F12229

F12250

F12251

F12259

F12280

F12288

F1229

F12920

F12921

F12922

F12929

F12950

F12951

F12959

F12980

F12988

F1299

F1310

F1311

F13120

F13121

F13129

F1314

F13150

F13151

F13159

F13180

F13181

F13182

F13188

F1320

F1321

F13220

F13221

F13229

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F13259

F1326

F1327

F13280

F13281

F13282

F13288

F13920

F13921

F13929

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F13959

F1396

F1397

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14121

F14122

F14129

F1414

F14150

F14151

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14221

F14222

F14229

F1423

F1424

F14250

F14251

F14259

F14280

F14281

F14282

F14288

F1429

F14920

F14921

F14922

F14929

F1494

F14950

F14951

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15121

F15122

F15129

F1514

F15150

F15151

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15221

F15222

F15229

F1523

F1524

F15250

F15251

F15259

F15280

F15281

F15282

F15288

F1529

F15920

F15921

F15922

F15929

F1593

F1594

F15950

F15951

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16121

F16122

F16129

F1614

F16150

F16151

F16159

F16180

F16183

F16188

F1619

F1620

F1621

F16220

F16221

F16229

F1624

F16250

F16251

F16259

F16280

F16283

F16288

F1629

F16920

F16921

F16929

F1694

F16950

F16951

F16959

F16980

F16983

F16988

F1699

F1810

F1811

F18120

F18121

F18129

F1814

F18150

F18151

F18159

F1817

F18180

F18188

F1819

F1820

F1821

F18220

F18221

F18229

F1824

F18250

F18251

F18259

F1827

F18280

F18288

F1829

F1890

F18920

F18921

F18929

F1894

F18950

F18951

F18959

F1897

F18980

F18988

F1899

F1910

F1911

F19120

F19121

F19122

F19129

F1914

F19150

F19151

F19159

F1916

F1917

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F19221

F19222

F19229

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F19259

F1926

F1927

F19280

F19281

F19282

F19288

F1929

F19920

F19921

F19922

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F19959

F1996

F1997

F19980

F19981

F19982

F19988

F1999

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F308

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F330

F331

F332

F333

F338

F3341

F3342

F339

F340

F341

F3481

F3489

F349

F39

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F520

F521

F5221

F5222

F5231

F5232

F524

F525

F526

F528

F529

F53

F54

F550

F551

F552

F553

F554

F558

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F650

F651

F652

F653

F654

F6551

F6552

F6581

F6589

F659

F66

F6810

F6811

F6812

F6813

F69

F70

F800

F801

F802

F804

F8082

F809

F8181

F819

F82

F840

F842

F843

F845

F849

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F950

F951

F952

F959

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

G300

G301

G308

G309

G3101

G3109

G3184

G4720

G4721

G4722

G4723

G4724

G4725

G4726

G4727

G4729

I69212

O906

R413

R41840

R41841

R41842

R41843

R41844

R4189

R45850

R45851

T5892XD

T5892XS

T7401XA

T7401XD

T7401XS

T7402XA

T7412XD

T7412XS

T7421XA

T7421XD

T7421XS

T7422XA

T7422XD

T7422XS

T7431XA

T7431XD

T7431XS

T7432XA

T7432XD

T7432XS

T7601XA

T7601XD

T7601XS

T7602XA

T7602XD

T7602XS

T7611XA

T7611XD

T7611XS

T7612XA

T7612XD

T7612XS

T7621XA

T7621XD

T7621XS

T7622XA

T7622XD

T7622XS

T7631XA

T7631XD

T7631XS

T7632XA

T7632XD

T7632XS

Z0389

Z600

Z608

Z609

Z620

Z621

Z622

Z6221

Z62810

Z62811

Z62812

Z62820

Z62821

Z62822

Z62890

Z6331

Z6332

Z634

Z635

Z6372

Z638

Z644

Z654

Z655

Z658

Z69010

Z69011

Z69020

Z69021

Z6912

Z6982

Z72810

Z72811

Z736

Z781

Z818

Z8651

Z9183

In addition to the diagnosis codes listed in the table above, procedure codes 90791 and 90792 are a benefit when submitted with the following diagnosis codes:

Diagnosis Codes

F71

F72

F73

F78

F79

Procedure codes 96101, 96116, and 96118 are limited to the following diagnosis codes:

Diagnosis Codes

A8100

A8101

A8109

A8181

A8183

B1001

B1009

B451

D8681

E7500

E7501

E7502

E7509

E7510

E7511

E7519

E7523

E7525

E7529

E754

F0150

F0151

F0280

F0281

F0390

F0391

F04

F05

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0781

F0789

F09

F1010

F1011

F10120

F10121

F10129

F1014

F10150

F10151

F10159

F10180

F10181

F10182

F10188

F1019

F1020

F1021

F10220

F10221

F10229

F10230

F10231

F10232

F10239

F1024

F10250

F10251

F10259

F1026

F1027

F10280

F10281

F10282

F10288

F1029

F10920

F10921

F10929

F1094

F10950

F10951

F10959

F1096

F1097

F10980

F10981

F10982

F10988

F1099

F1110

F1111

F11120

F11121

F11122

F11129

F1114

F11150

F11151

F11159

F11181

F11182

F11188

F1119

F1120

F1121

F11220

F11221

F11222

F11229

F1123

F1124

F11250

F11251

F11259

F11281

F11282

F11288

F1129

F11920

F11921

F11922

F11929

F1193

F1194

F11950

F11951

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12121

F12122

F12129

F12150

F12151

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12221

F12222

F12229

F12250

F12251

F12259

F12280

F12288

F1229

F1290

F12920

F12921

F12922

F12929

F12950

F12951

F12959

F12980

F12988

F1299

F1310

F1311

F1314

F13120

F13121

F13129

F13150

F13151

F13159

F13180

F13181

F13182

F13188

F1320

F1321

F13220

F13221

F13229

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F13259

F1326

F1327

F13280

F13281

F13282

F13288

F13920

F13921

F13929

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F13959

F1396

F1397

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14121

F14122

F14129

F1414

F14150

F14151

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14221

F14222

F14229

F1423

F1424

F14250

F14251

F14259

F14280

F14281

F14282

F14288

F1429

F14920

F14921

F14922

F14929

F1494

F14950

F14951

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15121

F15122

F15129

F1514

F15150

F15151

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15221

F15222

F15229

F1523

F1524

F15250

F15251

F15259

F15280

F15281

F15282

F15288

F1529

F15920

F15921

F15922

F15929

F1593

F1594

F15950

F15951

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16121

F16122

F16129

F1614

F16150

F16151

F16159

F16180

F16183

F16188

F1619

F1620

F1621

F16220

F16221

F16229

F1624

F16250

F16251

F16259

F16280

F16283

F16288

F1629

F16920

F16921

F16929

F1694

F16950

F16951

F16959

F16980

F16983

F16988

F1699

F1810

F1811

F18120

F18121

F18129

F1814

F18150

F18151

F18159

F1817

F18180

F18188

F1819

F1820

F1821

F18220

F18221

F18229

F1824

F18250

F18251

F18259

F1827

F18280

F18288

F1829

F1890

F18920

F18921

F18929

F18950

F18951

F18959

F1897

F18980

F18988

F1894

F1899

F1910

F1911

F19120

F19121

F19122

F19129

F1914

F19150

F19151

F19159

F1916

F1917

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F19221

F19222

F19229

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F19259

F1926

F1927

F19280

F19281

F19282

F19288

F1929

F19920

F19921

F19922

F19929

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F19959

F1996

F1997

F19980

F19981

F19982

F19988

F1999

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F308

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F330

F331

F332

F333

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F520

F521

F5221

F5222

F5231

F5232

F524

F525

F526

F528

F529

F53

F54

F550

F551

F552

F553

F554

F558

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F650

F651

F652

F653

F654

F6551

F6552

F6581

F6589

F659

F66

F6810

F6811

F6812

F6813

F688

F69

F70

F71

F72

F73

F78

F79

F800

F801

F802

F804

F8082

F8089

F809

F810

F812

F8181

F819

F82

F840

F842

F843

F845

F848

F849

F88

F89

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F950

F951

F952

F958

F959

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

G000

G001

G002

G003

G008

G009

G01

G02

G030

G031

G032

G038

G039

G0400

G0401

G0402

G042

G0430

G0431

G0432

G0439

G0481

G0489

G0490

G0491

G053

G054

G060

G061

G062

G07

G210

G300

G301

G308

G309

G3101

G3109

G311

G312

G3181

G3182

G3183

G3184

G3185

G3189

G319

G3289

G35

G40001

G40009

G40011

G40019

G40B01

G40B09

G40B11

G40B19

G40101

G40109

G40111

G40119

G40201

G40209

G40211

G40219

G40301

G40309

G40311

G40319

G40501

G40509

G40801

G40802

G40803

G40804

G40811

G40812

G40813

G40814

G40821

G40822

G40823

G40824

G4089

G40901

G40909

G40911

G40919

G40A01

G40A09

G40A11

G40A19

G44209

G450

G451

G452

G454

G458

G459

G468

G4720

G4721

G4722

G4723

G4724

G4725

G4726

G4727

G4729

G910

G911

G912

G92

G930

G931

G9340

G9341

G9349

G937

G9381

G9389

G939

G94

H93291

H93292

H93293

H93A1

H93A2

H93A3

H93A9

I6000

I6001

I6002

I6010

I6011

I6012

I602

I6030

I6031

I6032

I604

I6050

I6051

I6052

I606

I607

I608

I609

I610

I611

I612

I613

I614

I615

I616

I618

I619

I6200

I6201

I6202

I6203

I621

I629

I6300

I63011

I63012

I63013

I63019

I6302

I63031

I63032

I63033

I63039

I6309

I6310

I63111

I63112

I63113

I63119

I6312

I63131

I63132

I63133

I63139

I6319

I6320

I63211

I63212

I63213

I63219

I6322

I63231

I63232

I63233

I63239

I6329

I6330

I63311

I63312

I63313

I63319

I63321

I63322

I63323

I63329

I63331

I63332

I63333

I63339

I63341

I63342

I63343

I63349

I6339

I6340

I63411

I63412

I63413

I63419

I63421

I63422

I63423

I63429

I63431

I63432

I63433

I63439

I63441

I63442

I63443

I63449

I6349

I6350

I63511

I63512

I63513

I63519

I63521

I63522

I63523

I63529

I63531

I63532

I63533

I63539

I63541

I63542

I63543

I63549

I6359

I6501

I6502

I6503

I6509

I651

I6521

I6522

I6523

I6529

I658

I659

I6601

I6602

I6603

I6609

I6611

I6612

I6613

I6619

I6621

I6622

I6623

I6629

I663

I668

I669

I671

I672

I674

I675

I676

I677

I6781

I6782

I6789

I679

I680

I682

I688

I6900

I69010

I69011

I69012

I69013

I69014

I69015

I69018

I69019

I69020

I69021

I69022

I69023

I69028

I69031

I69032

I69033

I69034

I69039

I69041

I69042

I69043

I69044

I69049

I69051

I69052

I69053

I69054

I69059

I69061

I69062

I69063

I69064

I69065

I69069

I69090

I69091

I69092

I69093

I69098

I6910

I69110

I69111

I69112

I69113

I69114

I69115

I69118

I69119

I69120

I69121

I69122

I69123

I69128

I69131

I69132

I69133

I69134

I69139

I69141

I69142

I69143

I69144

I69149

I69151

I69152

I69153

I69154

I69159

I69161

I69162

I69163

I69164

I69165

I69169

I69190

I69191

I69192

I69193

I69198

I6920

I69210

I69211

I69212

I69213

I69214

I69215

I69218

I69219

I69220

I69221

I69222

I69223

I69228

I69231

I69232

I69233

I69234

I69239

I69241

I69242

I69243

I69244

I69249

I69251

I69252

I69253

I69254

I69259

I69261

I69262

I69263

I69264

I69265

I69269

I69290

I69291

I69292

I69293

I69298

I6930

I69310

I69311

I69312

I69313

I69314

I69315

I69318

I69319

I69320

I69321

I69322

I69323

I69328

I69331

I69332

I69333

I69334

I69339

I69341

I69342

I69343

I69344

I69349

I69351

I69352

I69353

I69354

I69359

I69361

I69362

I69363

I69364

I69365

I69369

I69390

I69391

I69392

I69393

I69398

I6980

I69810

I69811

I69812

I69813

I69814

I69815

I69818

I69819

I69820

I69821

I69822

I69823

I69828

I69831

I69832

I69833

I69834

I69839

I69841

I69842

I69843

I69844

I69849

I69851

I69852

I69853

I69854

I69859

I69861

I69862

I69863

I69864

I69865

I69869

I69890

I69891

I69892

I69893

I69898

I6990

I69910

I69911

I69912

I69913

I69914

I69915

I69918

I69919

I69920

I69921

I69922

I69923

I69928

I69931

I69932

I69933

I69934

I69939

I69941

I69942

I69943

I69944

I69949

I69951

I69952

I69953

I69954

I69959

I69961

I69962

I69963

I69964

I69965

I69969

I69990

I69991

I69992

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Z73812

Z73819

Z781

Z818

Z8651

Z8659

Z87820

Z87890

Z9183

4.2.1Telemedicine and Telehealth

Certain outpatient mental health services may be provided by distant site providers through telemed­icine or telehealth when billed with modifier 95.

Mental health services delivered through telemedicine or telehealth do not require a patient site presenter unless the patient is experiencing a mental health emergency.

Refer to:  The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more infor­mation about telemedicine and telehealth.

4.2.2Psychotherapy

Individual psychotherapy is therapy that focuses on a single client.

Group psychotherapy is a type of psychotherapy that involves one or more therapists working with several clients at the same time.

Family psychotherapy is therapy that focuses on the dynamics of the family unit where the goal is to strengthen the family’s problem solving and communication skills.

Providers must bill a modifier to identify a separate and distinct service when performing individual psychotherapy (procedure codes 90832, 90834, and 90837) and family psychotherapy (procedure codes 90846 or 90847) on the same day for the same client. When billing for these services, providers must submit the family psychotherapy procedure code with the modifier on the claim to indicate that the procedure or service was distinct or independent from other services performed on the same day for the same client. Documentation that supports the provision of distinct or independent services must be maintained in the client’s medical record and made available to Texas Medicaid upon request.

Prolonged psychotherapy services delivered in addition to procedure code 90837 should be billed using the appropriate prolonged services add-on code (procedure code 99354 or 99355)

Note:The add-on codes may only be billed by physician, APRN, or PA providers.

Refer to:  Subsection 9.2.56.7, “Prolonged Physician Services” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about prolonged physician services.

Psychotherapy (individual, family, or group) is limited to 4 hours per client, per day.

Psychotherapy is limited to 30 individual, group, or family psychotherapy visits per client, per calendar year. Additional psychotherapy services must be prior authorized. Prior authorization requests in incre­ments of up to 10 additional visits may be considered. The request must be submitted on an Outpatient Mental Health Services Request Form and include the following information:

Identifying client information

Provider name and identifier

Current DSM diagnosis(es)

Current psychotropic medications

Current symptoms requiring additional psychotherapy

Treatment plan, including measurable short term goals, specific therapeutic interventions utilized, and measurable expected outcomes of therapy

Number and type of services requested and anticipated dates that the services will be provided

Indication of court-ordered or DFPS-directed services

Providers with established clients must request prior authorization when they determine the client is approaching 30 psychotherapy visits for the calendar year. If the client changes providers during the year and the new provider is unable to obtain complete information on the client’s previous treatment history, providers are encouraged to obtain prior authorization before rendering services. Requests submitted on the same day as the initial session with a new provider will be considered based on medical necessity criteria.

Providers must bill the preponderance of each half hour of psychotherapy and indicate the number of units on the claim form.

LMFTs must bill with modifier U8 to differentiate from LPCs.

Supporting documentation for individual, family, or group psychotherapy must include:

Start and end time of session

Modality or modalities utilized

Frequency of psychotherapy sessions

Clinical notes for each encounter must include: diagnosis; symptoms; functional status; focused mental status examination, if indicated; treatment plan, prognosis, and progress; name, signature and credentials of person performing the service

4.2.2.1Family Psychotherapy

Family psychotherapy may be provided to Medicaid clients 20 years of age and younger using procedure code 90846 or clients of any age using procedure code 90847.

Family psychotherapy is only reimbursable for one Medicaid eligible client per session regardless of the number of family members present per session.

Family psychotherapy for Medicaid clients 20 years of age and younger may be provided to the child’s parent(s), foster parent(s), or legal guardian without the child present, as clinically appropriate, using procedure code 90846. Parent- or guardian-only sessions may be indicated when addressing sensitive topics such as parenting challenges or related stressors that would be inappropriate to discuss with the child present at the session.

Only the following specific relatives are allowed to participate in family psychotherapy services:

Biological parent, foster parent, or legal guardian

Child

Grandfather or grandmother

Sibling (biological, foster, or kinship)

Uncle, aunt, nephew, or niece

First cousin or first cousin once removed

Stepfather, stepmother, stepbrother, or stepsister

4.2.2.2Treatment for Alzheimer’s Disease and Dementia

Psychotherapy for clients with Alzheimer’s disease or dementia may be a benefit of Texas Medicaid for clients with very mild or mild cognitive decline.

Documentation to support the treatment for Alzheimer’s disease or dementia must be maintained in the client’s medical record and may be subject to retrospective review. Psychotherapy services must not be continued if no longer beneficial to the client due to diminished cognitive functioning.

4.2.3Delegated Services

Services provided by a psychologist, LPA, PLP, psychology intern, or post-doctoral fellow must be billed with a modifier. Psychological services provided by an LPA, PLP psychology intern, or post-doctoral fellow must be billed under the supervising psychologist’s Medicaid provider identifier or the Medicaid identifier of the legal entity employing the supervising psychologist.

Services performed by the LPA or PLP will be reduced to 70 percent of the psychologist reimbursement fee schedule rate. Services performed by the psychology intern or post-doctoral fellow will be reduced to 50 percent of the psychologist reimbursement fee schedule rate.

The following modifiers are to be used with procedure codes for licensed psychologist and delegated services:

Modifier

Description

AH

Identified service provided by a clinical psychologist

UB

Identifies service provided by a pre-doctoral psychology intern or post-doctoral psychology fellow

UC

Identifies service provided by an LPA

U9

Identifies service provided by a PLP

Claims submitted without a modifier or with two of these modifiers on the same detail will be denied.

Only the LCSW, LMFT, LPC, APRN, or PA actually performing the mental health service may bill Texas Medicaid. The LCSW, LMFT, LPC, APRN, or PA must not bill for services performed by people under his or her supervision.

4.2.4Pharmacological Management

Pharmacological management is the in-depth management of psychopharmacological agents to treat a client’s mental health symptoms.

Pharmacological management is a physician service and cannot be provided by a non-physician or “incident to” a physician service, with the exception of APRNs and PAs whose scope of license in this state permits them to prescribe.

Pharmacological management is limited to one service per day, per client, by any provider in any setting.

The treating provider should use the most appropriate E/M code for the pharmacological management visit depending on the place of service and complexity of the client’s condition, along with modifier UD to designate the visit as primarily focused on pharmacological management.

Supporting documentation for pharmacological management must include:

A complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

Current list of medications

Current psychiatric symptoms and problems, to include presenting mental status

Problems, reactions, and side effects, if any, to medications

Any medication modifications made during visit and the reasons for medication adjustments, changes, or discontinuation

Desired therapeutic drug levels, if applicable, for medications requiring blood level monitoring, e.g. Lithium

Current laboratory values, if applicable, for medications requiring monitoring for potential side effects, e.g. hyperglycemia caused by anti-psychotic medications

Treatment goals

4.2.5Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is the induction of convulsions by the passage of an electric current through the brain used in the treatment of certain psychiatric disorders.

Individual psychotherapy, psychological testing, neurobehavioral testing, or neuropsychological testing billed in addition to ECT on the same day, by any provider will be denied as part of another procedure on the same day.

ECT billed in addition to psychiatric diagnostic evaluation, group psychotherapy, or family psycho­therapy on the same day, by the same provider will be denied as part of another procedure.

4.2.6Psychiatric Diagnostic Evaluation

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. Psychiatric diagnostic evaluation with medical services also includes a medical assessment, other physical examination elements as indicated, and may also include prescription of medications, and laboratory or other diagnostic studies.

A psychiatric diagnostic evaluation (without medical services) (procedure code 90791) may be reimbursed to psychiatrists, psychologists, APRNs, PAs, LCSWs, LPCs, and LMFTs.

A psychiatric diagnostic evaluation (with medical services) (procedure code 90792) may be reimbursed to psychiatrists, APRNs, and PAs.

Psychiatric diagnostic evaluations (procedure codes 90791 or 90792) are limited to once per client, per rolling year, same provider in the office, home, outpatient hospital, or other settings, regardless of the number of professionals involved in the interview. Additional psychiatric diagnostic evaluations may be considered for prior authorization on a case-by-case basis when submitted on an Outpatient Mental Health Services Request Form with supporting documentation, including but not limited to:

A court order or a Department of Family and Protective Services (DFPS) directive

If a major change of status occurs

Supporting documentation for psychiatric diagnostic evaluations must include:

Reason for referral and/or presenting problem

Prior diagnoses and any prior treatment

Other pertinent medical, social, and family history

Clinical observations and results of mental status examination

A complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

Recommendations, including expected long term and short term goals

4.2.7Psychological, Neurobehavioral, and Neuropsychological Testing

Psychological, neurobehavioral, and neuropsychological testing involves the use of formal tests and other assessment tools to measure and assess a client’s emotional, and cognitive functioning in order to arrive at a diagnosis and guide treatment.

Psychological testing (procedure code 96101), neurobehavioral testing (procedure code 96116), and neuropsychological testing (procedure code 96118) is limited to four hours per client, per day and eight hours per client, per calendar year. Additional hours require prior authorization when medically necessary. The request must be submitted on an Outpatient Mental Health Services Request Form and include the following information:

Identifying client information

Provider name and identifier

Current DSM diagnosis(es)

Indication of court-ordered or DFPS-directed services

Type of testing requested (psychological, neurobehavioral, or neuropsychological) including specific procedure code(s)

Rationale for requested testing, to include current client symptoms

Previous history and testing results

Psychological, neurobehavioral, and neuropsychological testing will not be reimbursed to an APRN or a PA. The most appropriate office encounter/visit procedure code must be billed. Mental health screening may be performed during an assessment by an APRN or a PA, but will not be reimbursed separately.

Psychological testing (procedure code 96101) or neuropsychological testing (procedure code 96118) may be reimbursed on the same date of service as an initial psychiatric diagnostic evaluation (procedure code 90791 or 90792).

Neurobehavioral testing (procedure code 96116) may not be reimbursed on the same date of service as an initial psychiatric diagnostic evaluation (procedure code 90791 or 90792) to the same provider.

Psychological testing (procedure code 96101), neurobehavioral testing (procedure code 96116), and neuropsychological testing (procedure code 96118) will not be paid for the same date of service to the same provider. All documentation must be maintained by the provider in the client’s medical record.

The reimbursement for procedure codes 96101, 96116, and 96118 includes the face-to-face testing and the scoring and interpretation of the results. The number of units in the claim must reflect the time spent face-to-face performing testing with the client plus the time spent scoring and interpreting the results in one hour increments.

Assessment, treatment planning, and documentation time, including time to document test results in the client’s medical record, is not reimbursed separately. Reimbursement is included in the covered procedure codes.

4.2.7.1Testing in Facilities

Psychological testing, neurobehavioral testing, or neuropsychological testing may be reimbursed when provided in a skilled nursing facility (SNF), intermediate care facility (ICF), or extended care facility (ECF) as clinically indicated. Testing may be indicated, for example, when a resident has experienced a significant change in mental status requiring specialized testing, or to evaluate a patient’s competency to return to a community-based setting. Patients with well-established mental or cognitive issues do not require additional testing.

Psychological, neurobehavioral, or neuropsychological testing will not be reimbursed in a SNF, ICF, or ECF when conducted prior to the performance of initial intake assessments such as the Minimum Data Set or Preadmission Screening and Resident Review (PASRR) (a completed Level I Screening and a Level II Evaluation, as applicable).

Supporting documentation for psychological, neurobehavioral, or neuropsychological testing must include:

Reason for referral and/or presenting problem

The name of the tests (e.g.,WAIS-R, Rorschach, MMPI) performed

The scoring of the test

Location the testing is performed

The name and credentials of each provider involved in administering, interpreting, and preparing the report

Interpretation of the test to include narrative descriptions of the test findings

Length of time spent by each provider, as applicable, in face-to-face administration, interpretation, integrating the test interpretation, and documenting the comprehensive report based on the integrated data

Recommended treatment, including how test results affect the prescribed treatment

Recommendations for further testing to include an explanation to substantiate the necessity for retesting, if applicable

Rationale or extenuating circumstances that impact the ability to complete the testing, such as, but not limited to, the client’s condition requires testing over two days and client does not return, or the client’s condition precludes completion of the testing

The original testing material must be maintained by the provider and must be readily available for retro­spective review by HHSC.

When psychological, neurobehavioral, or neuropsychological testing is performed in a SNF, ICF, or ECF, a copy of the test and the resulting report must also be maintained in the patient’s medical record at the facility.

4.3Prior Authorization

Prior authorization requests may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. Performing providers may sign prior authorization forms and supporting documentation using electronic or wet signatures.

Refer to:  Subsection 5.5.1.2, “Document Requirements and Retention” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information about electronic signatures.

All providers are required to adhere to prior authorization requirements.

4.3.1Services Requiring Prior Authorization

Prior Authorization is required for the following services:

Psychiatric diagnostic evaluation (procedure codes 90791 and 90792) after the one evaluation per client, per provider, per rolling year limitation has been met

Individual, family, or group psychotherapy (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853) after the 30 visit per calendar year limitation has been met

Psychological testing (procedure code 96101), neurobehavioral testing (procedure code 96116), or neuropsychological testing (procedure code 96118) after the 4 hour per day or 8 hour per calendar year limitations have been met

Unlisted psychiatric service or procedure (procedure code 90899)

Requests for prior authorization for procedure code 90899 must be submitted by the provider to the Special Medical Prior Authorization (SMPA) department using the Special Medical Prior Authorization (SMPA) Request Form with documentation supporting medical necessity including:

Client’s diagnosis

Prior treatment for this diagnosis and the medical necessity of the requested procedure

A clear, concise description of the evidence-based service or procedure to be performed, and the intended fee for the service or procedure

The reason for recommending this particular service or procedure

A procedure code that is comparable to the service or procedure being requested

Documentation that this service or procedure is not investigational or experimental

4.3.2Prior Authorization Not Required

Prior authorization is not required for the following services:

One psychiatric diagnostic evaluation (procedure codes 90791 and 90792) per client, per rolling year, per provider (same provider)

30 individual, family, or group psychotherapy (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853) visits per client per calendar year

4 hours of psychotherapy services per client per day

4 hours of psychological, neurobehavioral, or neuropsychological testing (procedure codes 96101, 96116, and 96118) per client per day

8 hours of psychological, neurobehavioral, or neuropsychological testing (procedure codes 96101, 96116, and 96118) per client, per calendar year

Electroconvulsive therapy (procedure code 90870)

4.4Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including mental health services. The documentation must support the medical necessity of the treatment for its entire duration.

Mental health services outlined in this handbook are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the services provided.

4.5Twelve Hour System Limitation

The following provider types are limited to a maximum combined total of 12 hours per provider, per day, regardless of the number of patients seen for outpatient mental health services:

Psychologist

APRN

PA

LCSW

LMFT

LPC

The following table lists the procedure codes for mental health services included in the system limitation, along with the time increments the system will apply based on the billed procedure code. The time incre­ments applied will be used to calculate the 12-hour per day system limitation.

Procedure Code

Time Applied

90791

60 minutes

90792

60 minutes

90832

30 minutes

90833*

30 minutes

90834

45 minutes

90836*

45 minutes

90837

60 minutes

90838*

60 minutes

90846

50 minutes

90847

50 minutes

96101

60 minutes

96116

60 minutes

96118

60 minutes

* Add-on procedure codes to be billed with the most appropriate E/M procedure code.

Court-ordered and DFPS directed services are not subject to the 12-hour per provider, per day system limitation when billed with modifier H9.

Physicians are not subject to the 12-hour system limitation since they can delegate and may submit claims in excess of 12 hours per day.

Psychologists can delegate to multiple LPAs, PLPs, interns, or post-doctoral fellows and therefore delegated services are not subject to the 12-hour system limitation since they may submit claims for delegated services in excess of 12 hours per day.

4.6Exclusions

The following services are not benefits of Texas Medicaid:

Psychoanalysis

Multiple Family Group Psychotherapy

Marriage or couples counseling

Narcosynthesis

Biofeedback training as part of psychophysiological therapy

Psychiatric Day Treatment Programs

Services provided by a psychiatric assistant, psychological assistant (excluding Master’s level LPA), or a licensed chemical dependency counselor

4.7Claims Filing and Reimbursement

Providers must bill Medicare before Medicaid when clients are eligible for services under both programs. Medicaid’s responsibility for the coinsurance or deductible is determined in accordance with Medicaid benefits and limitations. Providers must check the client’s Medicare card for Part B coverage before billing Medicaid. When Medicare is primary, it is inappropriate to bill Medicaid without first billing Medicare.

Note:Texas Medicaid may reimburse the full amount of the Medicare coinsurance and deductible for services rendered by LCSW providers.

Refer to:  Subsection 2.7.2, “Part B” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

Subsection 4.11.2, “Medicare Part B Crossovers” in “Section 4: Client Eligibility” (Vol. 1, General Information) for information about how coinsurance and deductibles may be reimbursed by Texas Medicaid.

LCSW, LMFT, and LPC services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

According to 1 TAC §355.8091, the Texas Medicaid rate for LCSWs, LMFTs, and LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com. Under 1 TAC §355.8261, an FQHC is reimbursed according to its specific prospective payment system (PPS) rate per visit for LCSW services.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the Reimbursement Rate Changes page of the TMHP website at www.tmhp.com.

Note:Texas Medicaid may reimburse the full amount of the Medicare coinsurance and deductible for services rendered by LCSW providers.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

Subsection 4.5, “Twelve Hour System Limitation” in this handbook for details about the 12-hours-per-day behavioral health services limitation.

4.8NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manual. The CMS NCCI and MUE guidelines can be found in the NCCI Policy and Medicaid Claims Processing manuals, which are available on the CMS website. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

Whenever Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

5 Intellectual Disability Service Coordination, Mental Health Targeted Case Management, and Mental Health Rehabilitative Services

5.1Enrollment

5.1.1Local Intellectual and Developmental Disability Authority (LIDDA) Providers

A LIDDA provider who is authorized by the Department of Aging and Disability Services (DADS) to provide service coordination must be enrolled as a Long Term Care provider, and must submit claims through the Long Term Care system.

LIDDAs are the only entities that provide case management (service coordination) services to clients who have an intellectual disability.

Refer to:  The TMHP website at www.tmhp.com for additional information about Long Term Care enrollment and billing requirements.

5.1.2Local Mental Health Authority (LMHA) Providers

LMHA providers are authorized by the DSHS to provide targeted case management services and mental health rehabilitative services. To enroll in Texas Medicaid, LMHA providers must contact DSHS at 1-512-206-5288 to be approved.

5.1.3Non-Local Mental Health Authority (Non-LMHA) Providers

Non-LMHAs are private providers of both mental health (MH) case management and MH rehabilitative services, but they are not LMHAs. They must comply with all applicable federal and local laws and all of the regulations that are related to the services they provide. After receiving approval for enrollment in Texas Medicaid, the Non-LMHA provider must be credentialed by a Texas Medicaid managed care organization (MCO) to provide services to Texas Medicaid clients.

Non-LMHA providers also must register to use the DSHS Clinical Management for Behavioral Health Services (CMBHS) clinical record-keeping system before providing services to Texas Medicaid clients.

5.1.4Provider Credentials for Facilities Delivering MHTCM and Mental Health Rehabilitative Services

Community Services Specialist (CSSP), Qualified Mental Health Professional - Community Services (QMHP-CS), family partners, and peer providers are eligible to deliver some or all of the mental health rehabilitative services and mental health targeted case management services. The credentialing require­ments and services each provider may deliver are listed in the following sections.

Staff administering the assessment instruments must have documentation of current certification in the CANS or ANSA. Certification must be updated annually through an approved entity.

5.1.4.1Community Services Specialist (CSSP)

CSSP providers are eligible to deliver Mental Health Targeted Case Management (MHTCM) services and must meet the following minimum credentialing requirements:

High school diploma or high school equivalency

Three continuous years of documented full-time experience in the provision of mental health rehabilitative services prior to August 30, 2004

Demonstrated competency in the provision and documentation of mental health rehabilitative services

A CSSP performing MHTCM must:

Be certified as a Qualified Mental Health Professional - Community Services (QMHP-CS) or a CSSP.

Be an employee of the facility where the case management is delivered.

Be competent in the provision of MHTCM.

5.1.4.2Qualified Mental Health Professional - Community Services (QMHP-CS)

QMHP-CS providers are eligible to deliver MHTCM services and must meet one of the following minimum credentialing requirements:

Have done one of the following:

Completed a standardized training curriculum

Demonstrated competency in the work to be performed

Obtained a Bachelor’s degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabili­tation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention

Be a registered nurse (RN)

Staff administering the assessment instruments must have documentation of current certification in the Child and Adolescent Needs and Strengths Assessment (CANS) or the Adult Needs and Strengths Assessment (ANSA). Certification must be updated annually through an approved entity.

An individual who possesses any of the following licenses is considered a Licensed Practitioner of the Healing Arts (LPHA) and is automatically certified as a QMHP-CS:

Physician

Physician Assistant

Advanced Practice Registered Nurse

Psychologist

Licensed Clinical Social Worker (LCSW)

Licensed Marriage and Family Therapist (LMFT)

Licensed Professional Counselor (LPC)

A QMHP-CS must be clinically supervised by another QMHP-CS. If a QMHP-CS is clinically super­vised by another QMHP-CS, the supervising QMHP-CS must be clinically supervised by an LPHA.

5.1.4.3Peer Provider

Peer providers must have a high school diploma or high school equivalency, one cumulative year of receiving mental health services, and be clinically supervised by an LPHA. The supervising LPHA must conduct at least monthly documented meetings with the peer provider and conduct an additional monthly documented observation of the peer providing services.

A peer provider must satisfy all staff credentialing, competency, training, and clinical supervision requirements.

Services provided by a peer provider must be included in the treatment plan.

5.1.4.4Family Partner

A certified family partner must have a high school diploma or high school equivalency and one cumulative year of participating in mental health services as the parent or legally authorized represen­tative (LAR) of a child receiving mental health services.

A family partner must be supervised by at least a QMHP-CS and must satisfy all staff credentialing, competency, training, and clinical supervision requirements.

Services provided by a family partner must be included in the treatment plan.

Family partners must be credentialed as a certified family partner within one year of their hire date.

The family partner service is provided to parents or LARs for the benefit of the Medicaid eligible child.

5.1.4.5Certifications for Mental Health Rehabilitative Services

The following provider certifications are required for mental health rehabilitative services:

Service

Provider Types

 

QMHP-CS

CSSP

Peer Provider

Licensed Medical Personnel

Family Partner

RN

Medication Training and Support - Child, Youth, LAR, Primary Caregiver

X

X

 

X

X

X

Medication Training and Support - adult or LAR

X

X

X

X

 

X

Psychosocial Rehabili­tation (adults only)

X

X

X

X

 

X

Skills training and development - adult or LAR

X

X

X

X

 

X

Skills training and development - child/youth or LAR

X

X

 

X

X

X

Crisis Intervention

X

 

X

X

 

X

Day Program for Acute Needs - Symptoms management and functioning skills

X

X

X

X

 

X

Day Program for Acute Needs - Pharmacology issues

 

 

 

X

 

X

Day Program for Acute Needs - Psychiatric Nursing services

 

 

 

X

 

X

5.2Services, Benefits, Limitations, and Prior Authorization

5.2.1Intellectual and Developmental Disabilities Service Coordination

Texas Medicaid provides the following:

Service coordination for people who have an intellectual disability or a related condition (adult or child). Persons who have a related condition are eligible if they are being enrolled into the home and community based waiver (HCS); the Texas Home Living Waiver; or an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID).

Service coordination for persons who have an intellectual disability or a related condition who are enrolled in HCS or Texas Home Living waiver programs.

Service coordination funded by Medicaid as TCM is reimbursed by encounter.

There are two types of encounters:

Comprehensive encounter (Type A): A face-to-face contact with an individual to provide service coordination. The comprehensive encounter is limited to one billable encounter per individual per calendar month. DADS will not authorize payment for a comprehensive encounter that exceeds the cap of one encounter per individual per calendar month.

Supportive encounter (Type B): A face-to-face, telephone, or telemedicine contact with an individual or with a collateral on the individual’s behalf to provide service coordination.

A LIDDA is allowed up to three Type B encounters per calendar month for each Type A encounter that has occurred within the calendar month.

The Type B encounters are not limited to three per individual. Rather, the allowed Type B encounters may be delivered to any individual who needs a Type B encounter. These Type B encounters are allowable as long as the individual who received the Type B encounter also received a Type A encounter that same month.

For example, Sam and Mary receive a Type A encounter in June. It is allowable for the LIDDA to bill for one Type B encounter for Sam in June and five Type B encounters for Mary in June.

Payment for an individual’s Type B encounter is contingent on that individual having a Type A encounter within the same calendar month.

Within the calendar month, the Type A encounter does not have to occur on a date before any of the Type B encounters occur.

Prior authorization is not required for IDD coordination services.

5.2.2Mental Health Targeted Case Management (MHTCM)

Targeted case management services are case management services to clients within targeted groups. The target population that may receive Mental Health Targeted Case Management (MHTCM) as part of the Texas Medicaid Program are clients, regardless of age, with a single diagnosis of chronic mental illness or a combination of chronic mental illnesses as defined in the latest edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), and who have been determined via a uniform assessment process to be in need of MHTCM services. Clients of any age with a single diagnosis of intellectual and developmental disabilities (IDD) and related conditions, or a single diagnosis of substance use disorder (SUD) are not eligible for MHTCM services.

MHTCM services are furnished to assist clients in gaining access to needed medical, social/behavioral, educational, and other services and supports.

MHTCM activities and services include:

A comprehensive assessment and periodic reassessment, as medically necessary, of individual needs to determine the need for any medical, educational, social/behavioral, or other services.

The development (and periodic revision, as medically necessary) of a specific care plan that:

Is based on the information collected through the assessment;

Specifies the goals and actions to address the medical, social/behavioral, educational, and other services and supports needed by the client;

Includes activities such as ensuring the active participation of the eligible client and working with the client (or the client’s authorized health care decision maker) and others to develop these goals; and

Identifies a course of action to respond to the assessed needs of the eligible client.

Making referrals and performing other related activities, such as scheduling an appointment on behalf of the client, to help an eligible client obtain needed services and supports, including activities that help link a client with:

Medical, social/behavioral, and educational providers; and

Other programs and services that are capable of providing needed services to address identified needs and achieve goals in the care plan.

Monitoring and performing the necessary follow-up that is necessary to ensure the care plan is implemented and adequately addresses the client’s needs.

MHTCM activities may be with the client, family members, LAR, providers, or other entities or individuals and conducted as frequently as necessary, and at least once annually, to determine whether the following conditions are met:

Services are being furnished in accordance with the client’s care plan;

Services in the care plan are adequate in amount, scope, and duration to meet the needs of the client; and

The care plan and service arrangements are modified when the client’s needs or status change.

MHTCM is a benefit for clients transitioning to a community setting for up to 180 consecutive days prior to leaving a nursing facility; however, MHTCM services are coordinated with and do not duplicate activities provided as part of nursing facility services and discharge planning activities.

MHTCM consists of intensive case management and routine case management. Intensive case management services are predominantly community-based case management activities provided to the client or to the LAR on behalf of the client (who may or may not be present) to assist a client and caregiver or LAR in obtaining and coordinating access to necessary care and services appropriate to the client’s needs. Routine case management services are primarily office-based case management activities that assist a client, caregiver, or LAR in obtaining and coordinating access to necessary care and services appropriate to the client’s needs.

Intensive case management and routine case management are benefits for clients who are 20 years of age and younger. Intensive case management and routine case management are not payable on the same day.

Routine case management is a benefit for clients who are 21 years of age and older.

Providers must use procedure code T1017 and the appropriate modifier for MHTCM:

Modifier

Description

TF

Routine Case Management

TG

Intensive Case Management

HA

Child/Adolescent Program

HZ

Funded by criminal justice agency

Procedure code T1017 is limited to the following diagnosis codes:

Diagnosis Codes

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0789

F09

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F330

F331

F332

F333

F3340

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4000

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F53

F54

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F6810

F6811

F6812

F6813

F69

F8082

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

F99

O906

T7402XA

T7402XD

T7402XS

T7412XA

T7412XD

T7412XS

T7422XA

T7422XD

T7422XS

T7602XA

T7602XD

T7602XS

T7612XA

T7612XD

T7612XS

T7622XA

T7622XD

T7622XS

An MHTCM reimbursable session is the provision of a case management activity by an authorized case manager during a face-to-face meeting with an individual who is authorized to receive that specific type of case management. A billable unit of MHTCM is 15 continuous minutes of contact.

MHTCM is not payable when delivered on the same day as psychosocial rehabilitative services.

The following activities are included in the MHTCM rate and will not be reimbursed separately:

Documenting the provision of MHTCM services.

On-going administration of the Uniform Assessment to determine amount, duration, and type of MHTCM.

Travel time required to provide MHTCM services at a location not owned, operated, or under arrangement with the provider.

Texas Medicaid must not be billed for MHTCM services provided before the establishment of a diagnosis of mental illness and the authorization of services.

5.2.2.1Collateral Contacts

MHTCM may include contacts with non-eligible individuals who are directly related to identifying the eligible client’s needs and care for the purposes of helping the eligible client access services, identifying needs and supports to assist the eligible client in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the eligible client’s needs.

MHTCM services involving collateral contacts are only payable when the client or LAR is also present during the case management session.

5.2.2.2Intensive Case Management

Intensive case management incorporates a wraparound approach to care planning and treatment plan implementation. The wraparound process is a strengths-based course of action involving a client and their family, including any additional people identified by the client, LAR, primary caregiver, and family, that results in a unique set of community services and natural supports that are individualized for the client to achieve a positive set of identified outcomes.

Intensive case management is primarily community-based, meaning that services are provided in whatever setting is clinically appropriate and client-centered.

A case manager assigned to a client who is authorized to receive intensive case management services must have completed training in the National Wraparound Implementation Center’s Wraparound Practice model and must incorporate wraparound process planning or other approved models in devel­oping a plan that addresses the client’s unmet needs across life domains.

The case manager must develop an intensive case management treatment plan based on the client’s needs that may include information across life domains from relevant sources.

The case manager must meet face-to-face with the client and the LAR or primary caregiver:

Within seven days after the case manager is assigned to the client;

Within seven days after discharge from an inpatient psychiatric setting, whichever is later; or

Document the reasons the meeting did not occur and meet at the soonest available opportunity.

The case manager must identify the client’s strengths, service needs, and assistance that will be required to address the identified needs in the plan.

The case manager must take steps that are necessary to assist the client in gaining access to the needed services and service providers, including:

Making referrals to potential service providers.

Initiating contact with potential service providers.

Arranging, and if necessary to facilitate linkage, accompanying the client to initial meetings and non-routine appointments.

Arranging transportation to ensure the client’s attendance.

Advocating with service providers.

Providing relevant information to service providers.

Monitoring the client’s progress toward the goals set forth in the plan.

5.2.2.2.1Authorization Requirements

LMHAs delivering services to fee-for-service clients must obtain authorization from their internal utili­zation management department. When providing care to clients enrolled in managed care, LMHAs and other providers contracted with MCOs must submit authorization requests to the MCO with whom the individual is enrolled. The MCO may choose to waive this authorization submission requirement. Additionally, MCOs must follow the requirements set forth in the Uniform Managed Care Manual regarding utilization management for targeted case management and mental health rehabilitative services.

Eligibility determinations occur at the facility providing targeted case management services using the Clinical Management of Behavioral Health Services (CMBHS) software system.

Criteria used to make these service determinations are from the recommended Level of Care (LOC) of the individual as derived from the Uniform Assessment (UA), the needs of the client, and the Texas Resilience and Recovery Utilization Management Guidelines.

In determining service, the Qualified Mental Health Professional-Community Services (QMHP-CS) or Licensed Practitioner of the Healing Arts (LPHA) performs a screening for eligibility utilizing the UA. The LPHA gives a diagnosis and determines if the services are medically necessary.

The LPHA determination of diagnosis shall include an interview with the individual conducted either in-person or via telemedicine or telehealth.

Refer to:  The Telecommunication Services Handbook (Vol. 2, Provider Handbooks).

A facility that provides MHTCM must ensure that at minimum a QMHP-CS administers the uniform assessment to the individual at specified intervals (every 90 calendar days for clients who are 20 years of age and younger and every 180 calendar days for clients who are 21 years of age and older), and obtains a recommended LOC for the client.

The facility must evaluate the clinical needs of the client to determine if the amount of MHTCM services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs and ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.

If the facility determines that the type of MHTCM services associated with the recommended LOC is sufficient to meet the client’s needs, the facility must submit a request for service authorization according to the recommended LOC.

If the facility determines that a LOC other than the recommended LOC is more appropriate for the client, the provider must submit a deviation request that includes:

A request for an authorization of an LOC that is higher or lower than initially recommended; and

The clinical justification for the request.

The clinical justification must include the specific reasons why the client requires interventions outside the recommended LOC. Client refusal of recommended LOC may be noted as part of the justification.

All plans of care are subject to retrospective review by the state.

5.2.2.3Eligibility and Service Determinations for Clients Who are 20 Years of Age and Younger

MHTCM is available to clients who are 20 years of age and younger with a diagnosis of mental illness (excluding a single diagnosis of IDD and related disorders, or a single diagnosis of SUD) or serious emotional disturbance and who:

Have a serious functional impairment; or

Are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or

Are enrolled in a school system’s special education program because of serious emotional disturbance.

The initial assessment is the clinical process of obtaining and evaluating historical, social/behavioral, functional, psychiatric, developmental, or other information from the individual seeking services to determine specific treatment and support needs.

Functioning is assessed using one of the following standardized assessment tools:

The Child and Adolescent Needs and Strengths Assessment (CANS) for clients who are 17 years of age and younger

The Adult Needs and Strengths Assessment (ANSA) and any necessary supplemental assessments for clients who are 18 years of age and older

Services and supports to be provided to the client are determined jointly by the client, family, and the provider.

MHTCM services authorized for care by the provider through a clinical override are eligible for the duration of the authorization.

Continued eligibility for MHTCM services is based on a reassessment every 90 calendar days by the provider and reauthorization of services by the facility. Assignment of diagnosis in the CMBHS is required at any time the DSM diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

5.2.2.4Eligibility and Service Determinations for Clients Who are 21 Years of Age and Older

MHTCM is available to clients who are 21 years of age and older and who have severe and persistent mental illnesses such as schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, or other severely disabling mental disorders (excluding a single diagnosis of IDD and related disorders, or a single diagnosis of SUD) which require crisis resolution or ongoing and long-term support and treatment.

Clients with schizophrenia and bipolar disorder are automatically eligible for services. Clients with any other mental health diagnoses require evidence of significant difficulty functioning across one or more domains such as work or school to be eligible for services.

Functioning is assessed using a standardized assessment tool called the Adult Needs and Strengths Assessment (ANSA).

Clients are reassessed every 180 calendar days for continued need for services.

Assignment of diagnosis in the CMBHS is required at any time the DSM diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

Clients with a diagnosis of schizophrenia or bipolar disorder are automatically eligible for continued services.

Clients with major depressive disorder whose level of functioning qualified them initially are also automatically eligible for continued services, regardless of whether their level of functioning has improved or not.

Clients with any other mental health diagnoses are eligible should their level of functioning continue to be significantly impaired, as evidenced by the results of a standardized assessment tool.

5.2.2.5Documentation Requirements

A comprehensive diagnosis must be included in the client record, including documentation of appli­cable diagnostic criteria according to the latest edition of the DSM, as well as the specific justification of need for services.

MHTCM services, including attempts to provide MHTCM services, must be documented in the client’s medical record.

For routine case management, the case manager must document the client’s strengths, service needs, and assistance required to address the service needs as well as the steps that are necessary to accomplish the goals required to meet the client’s service needs.

For intensive case management, the assigned case manager must include the intensive case management treatment plan in the client’s medical record and document steps taken to meet the client’s goals and needs in the client’s progress notes.

As a result of the face-to-face meetings, assessments, and reassessments conducted, the case manager must document the client’s identified strengths, service needs, and assistance given to address the identified need, and specific goals and actions to be accomplished.

The case manager must document the following for all services provided:

The event or behavior that occurs while providing the MHTCM service or the reason for the specific case management encounter

The person, persons, or entity, including other case managers, with whom the encounter or contact occurred

Collateral contacts such as contacts with non-eligible individuals that are directly related to identi­fying the needs and supports for helping the client access services and managing the client’s care, including coordination with other case managers

The recovery plan goal(s) that was the focus of the service, including the progress or lack of progress in achieving recovery plan goal(s)

The time line for obtaining the needed services

The specific intervention that is being provided

The date the MHTCM service was provided

The start and end time of the MHTCM service

The location where the MHTCM service was provided and whether it was a face-to-face or telephone contact

The name of the provider agency and the signature of the employee providing the MHTCM service, including their credentials

The time line for reevaluating the needed service

If the individual refuses MHTCM services, the case manager must document the reason for the refusal in the most appropriate area of the client’s medical record and request that the individual sign a waiver of MHTCM services that is filed in the client’s medical record.

The provider must retain documentation in compliance with applicable records retention requirements in federal and state laws, rules, and regulations.

5.2.2.6Exclusions

The following services are not covered by MHTCM:

Case management activities that are an integral component of another covered Medicaid service

The provision of a medical, educational, social/behavioral, or other service to which a client has been referred, including for foster care programs, services such as, but not limited to, the following:

Research gathering and completion of documentation required by the foster care program

Assessing adoption placements

Recruiting or interviewing potential foster care parents

Serving legal papers

Home investigations

Providing transportation, including transporting the client to his/her LAR/primary caregiver

Administering foster care subsidies

Making placement arrangements

Performing an activity that does not directly assist a client in gaining or coordinating access to needed services

Providing medical or nursing services

Performing preadmission or intake activities

Monitoring the client’s general health status

Performing outreach activities

Performing quality oversight of a service provider

Conducting utilization review or utilization management activities

Conducting quality assurance activities

Authorizing services or authorizing the provision of services

Services to inmates of public institutions

5.2.3Mental Health Rehabilitative Services

Mental health rehabilitative services are defined as providing assistance in maintaining or improving functioning and may be considered rehabilitative when necessary to help a client achieve a rehabilitation goal as defined in the treatment plan.

Mental health rehabilitative services may be provided to a client with a serious mental illness as defined in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

Mental health rehabilitative services are age-appropriate, individualized, and designed to ameliorate functional impairments that negatively affect any of the following:

Community integration

Community tenure

Behaviors resulting from serious mental illness (SMI) or severe emotional disturbance (SED) that interfere with a client’s ability to remain in the community as a fully integrated and functioning member of that community

Mental health rehabilitative services may include:

Medication training and support services

Psychosocial rehabilitative services

Skills training and development

Crisis intervention services

Day programs for acute needs

Mental health rehabilitative services may only be provided by a member of the client’s therapeutic team. The therapeutic team includes a sufficient number of staff to adequately address the rehabilitative needs of clients assigned to the team.

Team members must be appropriately credentialed and have completed required trainings to provide the full array of component services, have regularly scheduled team meetings either in person or by teleconference, and every member of the team must be knowledgeable of the needs and the services available to the specific clients assigned to the team.

Mental health rehabilitative services may be a benefit for clients residing in a nursing facility (NF) when medically necessary as determined via a uniform assessment protocol and determined through pread­mission screening and resident review (PASRR) to require specialized services.

The following procedure codes are a benefit for mental health rehabilitation:

Service Category

Procedure Codes

Modifiers

Day Program for Acute Needs

H2012

 

Medication Training and Support

H0034

HQ: group services for adults

HA/HQ: group services for child/youth

Crisis Intervention

H2011

HA: child/youth

Skills Training and Development

H2014

HQ: group services for adults

HA: individual services for child/youth

HA/HQ: group services for child/youth

Psychosocial Rehabilitation Services

H2017

TD: individual services provided by RN

HQ: group services

HQ/TD: group services provided by RN

ET: individual crisis services

Psychosocial rehabilitation is not reimbursable on the same day as mental health targeted case management or skills training and development.

Reimbursement for procedure codes H0034, H2012, H2014, and H2017 are limited to the following diagnosis codes:

Diagnosis Codes

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0789

F09

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F330

F331

F332

F333

F3340

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4000

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F53

F54

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F6810

F6811

F6812

F6813

F69

F8082

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

F99

O906

T7402XA

T7402XD

T7402XS

T7412XA

T7412XD

T7412XS

T7422XA

T7422XD

T7422XS

T7602XA

T7602XD

T7602XS

T7612XA

T7612XD

T7612XS

T7622XA

T7622XD

T7622XS

No diagnosis is required for crisis intervention services (procedure code H2011); however, all CMS 1500 claim forms require a diagnosis.

A Medicaid provider may only bill for medically necessary mental health rehabilitative services that are provided face-to-face to:

A Medicaid-eligible client;

The LAR of a Medicaid-eligible client who is 21 years of age and older (on behalf of the client); or

The LAR or primary caregiver of a Medicaid-eligible client who is 20 years of age and younger (on behalf of the client).

5.2.3.1Eligibility and Service Determinations for Clients Who are 20 Years of Age and Younger

Certain mental health rehabilitative services (crisis intervention services, medication training and support, and skills training and development) are available to clients who are 20 years of age and younger with a diagnosis of mental illness or serious emotional disturbance and who:

Have a serious functional impairment; or

Are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or

Are enrolled in a school system’s special education program because of serious emotional disturbance.

Functioning is assessed using a standardized assessment tool, the Child and Adolescent Needs and Strengths Assessment (CANS) for clients who are 17 years of age and younger and the ANSA for clients who are 18 years of age and older.

Continued eligibility for mental health rehabilitative services for clients who are 17 years of age and younger is based on a reassessment at least every 90 calendar days, or more frequently if clinically indicated by the provider. Clients who are 18 years of age and older are reassessed every 180 calendar days, or more frequently if clinically indicated by the provider.

Assignment of diagnosis in the Clinical Management for Behavioral Health Services (CMBHS) is required at any time the mental illness diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

The LPHA determination of diagnosis shall include an interview with the client conducted either in-person or via telemedicine or telehealth.

In order to complete a comprehensive diagnosis for a client, documentation of the required diagnostic criteria according to the latest version of the DSM, as well as the specific level of functioning, shall be included in the client record. This information shall be included as part of the required assessment information.

5.2.3.2Eligibility and Service Determinations for Clients Who are 21 Years of Age and Older

Clients who are 21 years of age and older with serious mental illness, determined to be medically necessary via a uniform assessment protocol, are eligible for Mental Health Rehabilitative Services if the client is:

A resident of the state of Texas.

Determined by a uniform assessment and clinician observation to require mental health rehabili­tative services.

An LPHA has made a determination that such services are medically necessary.

Mental health rehabilitative services are available to clients who are 21 years of age and older who have serious mental illnesses and significant functional impairments which require crisis resolution or ongoing treatment. Functioning is assessed using a standardized assessment tool, the Adult Needs and Strengths Assessment (ANSA).

Clients who are 18 years of age and older are reassessed for continued need for services at least every 180 calendar days, or more frequently if clinically indicated by the provider.

Assignment of diagnosis in the Clinical Management for Behavioral Health Services (CMBHS) is required at any time the mental illness diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

The LPHA determination of diagnosis shall include an interview with the client conducted either in-person or via telemedicine or telehealth.

In order to complete a comprehensive diagnosis for a client, documentation of the required diagnostic criteria according to the latest version of the American Psychiatric Association’s Diagnostic and Statis­tical Manual of Mental Disorders (DSM), as well as the specific level of functioning, shall be included in the client record. This information shall be included as part of the required assessment information.

Clients with a diagnosis of schizophrenia or bipolar disorder are automatically eligible for continued services. A client with major depressive disorder whose level of functioning qualified them initially also is automatically eligible for continued services, regardless of whether their level of functioning has improved or not. Clients with any other mental health diagnoses are eligible should their level of functioning continue to be significantly impaired, as evidenced by the results of a standardized assessment tool called the Adult Needs and Strengths Assessment (ANSA).

5.2.3.3Treatment Planning

Mental health rehabilitative services are part of a client’s treatment plan and are intended to:

Reduce a client’s functional impairments resulting from serious mental illness (SMI) for adults.

Reduce serious emotional disturbance in children.

Restore a client to his/her optimal functioning level in the community.

The treatment planning process for mental health rehabilitative services requires the active participation of the Medicaid eligible client or LAR when necessary due to the client’s age or legal status. Treatment plans are based on a comprehensive assessment and must address the client’s strengths, areas of need, the client’s preferences, and descriptions of the client’s treatment goals.

5.2.3.4Medication Training and Support

Medication training and support services consist of education and guidance about medications and their possible side effects. It is curriculum-based training and guidance that serves as an initial orientation for the client in understanding the nature of his/her mental illnesses or emotional disturbances and the role of medications in ensuring symptom reduction and increased tenure in the community.

Medication training and support includes:

Assisting the client to manage symptomology and maximize functioning.

Understanding the concepts of recovery and resilience within the context of the serious mental illness.

Developing an understanding of the relationship between mental illness and the medications prescribed to treat the illness.

The interaction of medication with other medications, diet, and mood altering substances.

Understanding the overdose precautions of the client’s medication.

The identification and management of potential side effects.

Learning self-administration of the client’s medication.

Necessity of taking medications prescribed and following the physician’s or other qualified health care professional’s orders.

Medication training and support is available to eligible clients. The LAR or primary caregiver may receive medication training and support services on behalf of an eligible client.

5.2.3.5Psychosocial Rehabilitative Services

Psychosocial rehabilitative services are social, behavioral, and cognitive interventions provided by members of a client’s therapeutic team that build on strengths and focus on restoring the client’s ability to develop and maintain social relationships, occupational or educational achievement, and other independent living skills that are affected by or the result of a serious mental illness in clients who are 17 years of age and older.

Psychosocial rehabilitative services include independent living services, coordination services, and employment, housing, and medication-related services. Psychosocial rehabilitative services may also address the impact of co-occurring disorders upon the client’s ability to reduce symptomology and increase daily functioning.

If psychosocial rehabilitation is in the treatment plan, the treatment plan cannot simultaneously include skills training and development or targeted case management services.

Psychosocial rehabilitative services may not be provided to a client who is currently admitted to a crisis stabilization unit.

5.2.3.5.1Independent Living Services

Independent living services assist a client in acquiring the most immediate, fundamental functional skills needed to enable the client to reside in the community and avoid more restrictive levels of treatment or reducing behaviors or symptoms that prevent successful functioning in the client’s environment of choice.

Independent living services include skills training and/or supportive interventions that focus on the improvement of communication skills, appropriate interpersonal behaviors, and other skills necessary for independent living or, when age appropriate, functioning effectively with family, peers, and teachers.

Training for independent living includes skills related to:

Personal hygiene.

Transportation utilization.

Money management.

The development of natural supports.

Access to needed services in the community (e.g., medical care, substance abuse services, legal services, living accommodations).

Social skills (e.g., communicating one’s needs to strangers and making appropriate choices for the use of leisure time).

5.2.3.5.2Coordination Services

Coordination services are training activities that assist a client in improving his or her ability to gain and coordinate access to necessary care and services appropriate to the needs of the client.

Training for coordination skills includes instruction and guidance in such areas as:

Identifying areas of need across all life domains.

Prioritizing needs and setting goals.

Identifying potential service providers and support systems.

Initiating contact with providers and support systems.

Participating in the development and subsequent revisions of their plan of care.

Coordinating their services and supports.

Advocating for necessary changes and improvements to ensure that they obtain maximum benefit from their services and supports.

5.2.3.5.3Employment-Related Services

Employment-related services provide supports and skills training that are not job-specific and focus on developing skills to reduce or manage the symptoms of serious mental illness that interfere with a client’s ability to make vocational choices or obtain or retain employment.

Included in employment-related services are activities such as:

Skills training related to task focus, task completion, planning and managing activities to achieve outcomes, personal hygiene, grooming and communication, and skills training related to securing appropriate clothing, developing natural supports, and arranging transportation.

Establishing supportive contacts related to the school or work-site situation to reduce or manage behaviors or symptoms related to the client’s mental illness or emotional disturbance that interfere with job performance or progress towards the development of skills that would enable the client to obtain or retain employment.

5.2.3.5.4Housing-Related Services

Housing-related services develop a client’s strengths and abilities to manage the symptoms of the client’s serious mental illness that interfere with the client’s capacity to obtain or maintain tenure in independent integrated housing.

Included in housing-related services are activities such as:

Skills training related to home maintenance and cleanliness.

Problem solving with landlord and other residents.

Maintaining appropriate interpersonal boundaries.

Establishing supportive contacts related to the housing situation to reduce or manage behaviors or symptoms related to the client’s mental illness or emotional disturbance that interfere with maintaining independent integrated housing.

5.2.3.5.5Medication-Related Services

Medication-related services provide individualized training regarding the client’s medication adherence and is different from medication-training and support.

Services consist of training and supportive interventions that focus on client-specific needs and goals regarding the administration of medication, monitoring efficacy and side effects of medication, and other nursing services that enable the client to attain or maintain an optimal level of functioning.

Medication-related services do not include services or activities that are incidental to services performed by a physician (or other qualified health care professional) during an evaluation and management services visit.

5.2.3.6Skills Training and Development

Skills training and development is training provided to an eligible client, the LAR, or primary caregiver on behalf of an eligible client.

The training addresses:

Serious mental illness or SED and symptom-related problems that interfere with the client’s functioning and living, working, and learning environment.

Provides opportunities for the client to acquire and improve skills needed to function as appropri­ately and independently as possible in the community.

The client’s community integration and increases his or her community tenure.

Skills training and supportive interventions focus on the improvement of communication skills, appro­priate interpersonal behaviors and other skills necessary for independent living or, when age appropriate, functioning effectively with family, peers, and teachers.

Skills training and development may include:

Skills related to personal hygiene.

Pro-social skills.

Assertiveness skills.

Anger management skills.

Stress reduction techniques.

Communication skills.

Transportation utilization.

Money management.

The development of natural supports.

Access to needed services in the community, e.g., medical care, substance abuse services, legal services, living accommodations.

Social skills (e.g., communicating one’s needs to strangers and making appropriate choices for the use of leisure time).

Skills training and development services consist of increasing the LAR’s or primary caregiver’s under­standing of and ability to respond to the client’s needs identified in the uniform assessment or documented in the treatment plan.

Clients receiving skills training and development are not eligible to simultaneously receive psychosocial rehabilitative services and both services should not be simultaneously listed in the client’s treatment plan.

5.2.3.7Crisis Intervention

Crisis intervention services are intensive community-based one-to-one services provided to clients who require services to control acute symptoms that place the client at immediate risk of hospitalization, incarceration, or placement in a more restrictive treatment setting.

This service includes assessment, behavioral skills training, problem-solving, and reality orientation to help clients identify and manage their symptoms of mental illness, and cope with stressors.

Crisis intervention services may be provided in extended observation or crisis residential units. Crisis intervention services may not be provided to a client who is currently admitted to a crisis stabilization unit.

Crisis intervention services consist of the following interventions:

An assessment of dangerousness of the client to self or others

The provision of emergency care services that include crisis screening and response, telephone access, emergency case services, urgent care services, routine care services, and access to emergency medical/crisis services

Behavior skills training to assist the client in reducing distress and managing symptoms

Problem-solving

Reality orientation to help the client identify and manage his or her symptoms of serious mental illness or SED

Providing instruction, structure, and emotional support to the client in adapting to and coping with immediate stressors

Crisis intervention services are available to eligible clients.

5.2.3.8Day Programs for Acute Needs

Day programs for acute needs provide short term, intensive treatment to an eligible client who is 18 years of age and older and who requires multidisciplinary treatment to stabilize acute psychiatric symptoms or prevent admission to a more restrictive setting. Day program services are a site-based treatment provided in a group modality.

Day programs for acute needs are provided in a highly structured and safe environment with constant supervision and ensure an opportunity for frequent interaction between a client and staff members.

Day programs for acute needs must at all times have sufficient staff to ensure safety and program adequacy according to an established staffing ratio and staff response times. This service focuses on intensive, medically-oriented, multidisciplinary interventions such as behavior skills training, crisis management, and nursing services that are designed to stabilize acute psychiatric symptoms.

These services may be provided in a residential facility; however, none of the residential facilities can contain greater than 16 beds.

Day programs for acute needs include:

Psychiatric nursing services.

Pharmacological instruction that addresses medication issues related to the crisis precipitating the need for provision of day programs for acute needs.

Symptom management training.

Functional skills training.

Day programs for acute needs must, at all times, have a sufficient number of staff members to ensure safety and program adequacy, and, at a minimum, include:

One RN for every 16 clients at the day program’s location,

One physician to be available by phone, with a response time not to exceed 15 minutes,

Two staff members who are QMHP-CSs, CSSPs, or peer providers at the day program’s location,

One additional QMHP-CS who is not assigned full-time to another day program to be physically available, with a response time not to exceed 30 minutes,

Additional QMHP-CSs, CSSPs, or peer providers at the day program’s location sufficient to maintain a ratio of one staff member to every four clients.

5.2.3.9Authorization Requirements

Providers must obtain prior authorization for mental health rehabilitative services, with the exception of crisis intervention services.

LMHAs delivering services to fee-for-service clients must obtain authorization from their internal utili­zation management department. When providing care to clients enrolled in managed care, LMHAs and other providers contracted with MCOs must submit authorization requests to the MCO with whom the individual is enrolled. The MCO may choose to waive this authorization submission requirement. Additionally, MCOs must follow the requirements set forth in the Uniform Managed Care Manual regarding utilization management for targeted case management and mental health rehabilitative services.

Eligibility determinations occur at the facility providing mental health rehabilitative services using the Clinical Management of Behavioral Health Services (CMBHS) software system.

Criteria used to make these service determinations are from the recommended LOC of the individual as derived from the Uniform Assessment (UA), the needs of the individual, and the Texas Resilience and Recovery Utilization Management Guidelines.

A facility that provides mental health rehabilitative services must ensure that at minimum a QMHP-CS administers the uniform assessment to the individual at specified intervals (every 90 calendar days for clients who are 20 years of age and younger and every 180 calendar days for clients who are 21 years of age and older), and obtains a recommended LOC for the individual.

The provider must evaluate the clinical needs of the individual to determine if the amount of services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs and ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.

Changes to the treatment plan with regard to type, amount, or duration of services must be approved by an LPHA practicing within the scope of his/her licensure.

If the facility determines that an LOC other than the recommended LOC is more appropriate for the individual, the provider must submit a deviation request that includes:

A request for an authorization of an LOC that is higher or lower than initially recommended.

The clinical justification for the request.

The clinical justification must include the specific reason(s) why the individual requires interventions outside the recommended LOC. Client refusal of recommended LOC may be noted as part of the justification.

All treatment plans are subject to retrospective review by the state.

5.2.3.9.1Reauthorization Requirements

A QMHP-CS must conduct the uniform assessment at specified intervals (every 90 calendar days for children/youth and every 180 calendar days for adults) to determine the type, amount, and duration of mental health rehabilitative services.

Prior to the expiration of the authorization period or depleting the amount of services authorized, the provider must make a determination of whether the client continues to need mental health rehabilitative services. An LPHA must also determine whether the continuing need for mental health rehabilitative services meets the definition of medical necessity.

If the determination is that the client continues to need mental health rehabilitative services and that such services are medically necessary, the provider must:

Request another authorization for the same type and amount of mental health rehabilitative service previously authorized; or

Submit a request, with documented clinical reasons for such request, to change the type or amount of mental health rehabilitative services previously authorized if:

The provider determines that the type or amount of mental health rehabilitative services previ­ously authorized is inappropriate to address the client’s needs.

The criteria described in the utilization management guidelines for changing the type or amount of mental health rehabilitative services has been met.

5.2.3.10Documentation Requirements

All services require documentation to support the medical necessity of the service rendered. An LPHA must document in the client’s medical record that mental health rehabilitative services are medically necessary when the services are authorized and reauthorized.

Clients determined to need mental health rehabilitative services must have a treatment plan developed by the Medicaid enrolled provider of mental health rehabilitative services that describes in writing the type, amount, and duration of mental health rehabilitative services determined to be medically necessary to meet the needs of the person.

A rehabilitative services provider must document the following for all mental health rehabilitative services:

The name of the client to whom the service was provided

The type of service provided

The specific goal or objective addressed, and the modality and method used to provide the service

The date the service was provided

The start and end time of the service

The location where the service was provided

The signature of the staff member providing the service and a notation of their credentials

Any pertinent event or behavior relating to the client’s treatment which occurs during the provision of the service

The outcome or progress in achieving treatment plan goals

In addition to the general requirements described above, when providing crisis services, a provider must document the following information:

Risk of suicide and/or homicide;

Substance use or abuse;

Trauma, abuse, or neglect;

The outcome of the crisis (e.g., client in hospital, client with friend and scheduled to see doctor at 9:00 a.m. the following day);

All actions (including rehabilitative interventions and referrals to other agencies) used by the provider to address the problems presented;

The response of the client, and if appropriate, the response of the LAR and family members;

Any pertinent event or behavior relating to the client’s treatment which occurs during the provision of the service; and

Follow up activities, which may include referral to another provider.

Documentation for day programs for acute needs must be made daily. Documentation must be made after each face-to-face contact occurs to provide the mental health rehabilitative service for all other services.

An LPHA must, within two business days after crisis intervention services are provided, determine whether the crisis intervention services met the definition of medical necessity. If medical necessity is met then the LPHA must document the medical necessity.

Services are subject to retrospective review and recoupment if documentation does not support the service billed.

A provider must retain documentation in compliance with applicable federal and state laws, rules, and regulations.

5.2.3.11Exclusions

Clients receiving psychosocial rehabilitation services are not eligible to simultaneously receive skills training and development or targeted case management services.

Mental health rehabilitative services do not include any of the following services that must be billed to Texas Medicaid:

Rehabilitative services provided:

Before the establishment of a diagnosis of mental illness and authorization of services.

To clients who reside in an institution for mental diseases.

To general acute care hospital inpatients.

Services to residents of institutions that furnish food, shelter, and treatment to four or more unrelated persons

Services to nursing facility residents who have not been identified through the PASSR process as needing specialized mental health services

Services to inmates of public institutions

Job task-specific vocational services;

Educational services;

Room and board residential costs;

Services that are an integral and inseparable part of another Medicaid-reimbursable service, including targeted case management services, residential rehabilitative behavioral health services, institutional and waiver services;

Services that are covered elsewhere in the state Medicaid plan;

Services to clients with a single diagnosis of intellectual or developmental disability or substance use disorder who do not have a co-occurring diagnosis of mental illness in adults or serious emotional disturbance in children;

Inpatient hospital services;

Respite services; or

Family support services.

5.2.3.12Non-reimbursable Activities

A Medicaid provider will not be reimbursed for a mental health rehabilitative service:

That is not included in the client’s treatment plan (except for crisis intervention services and psychosocial rehabilitative services provided in a crisis situation;

That is not authorized, except for crisis intervention services;

Provided in excess of the amount authorized;

Provided outside of the duration authorized;

Provided to a client receiving MH case management services;

That is not documented;

Provided to a client who does not meet the eligibility criteria;

Provided to a client who does not have a current uniform assessment (except for crisis intervention services);

Provided to a client who is not present, awake, and participating during such service;

Provided via electronic media;

A Medicaid provider will not be reimbursed for a crisis service provided to a client who does not have a serious mental illness.

The cost of the following activities is included in the Medicaid mental health rehabilitative services reimbursement rate(s) and may not be directly billed by the Medicaid provider:

Developing and revising the treatment plan and interventions that are appropriate to a client’s needs.

Staffing and team meetings to discuss the provision of mental health rehabilitative services to a specific client;

Monitoring and evaluating outcomes of interventions, including contacts with a person other than the client;

Documenting the provision of mental health rehabilitative services;

A staff member’s travel time to and from a location to provide mental health rehabilitative services;

All services provided within a day program for acute needs that are delivered by a staff member, including services delivered in response to a crisis or an episode of acute psychiatric symptoms; and

Administering the uniform assessment to clients who are receiving mental health rehabilitative services.

5.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including MH and IDD services.

MH and IDD services are subject to retrospective review and recoupment if documentation does not support the service billed.

5.4Claims Filing and Reimbursement

IDD service coordination, MHTCM, and mental health rehabilitative services must be submitted to TMHP in an approved electronic claims format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply them.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized state­ments, are not accepted as claim supplements.

Services are cost reimbursed in accordance with 1 TAC §§355.743, 355.746, and 355.781. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

5.4.1Managed Care Clients

Claims for managed care clients must be submitted to the client’s MCO. Mental health targeted case management and mental health rehabilitative services that are funded by a criminal justice agency (submitted with modifier HZ) are carved out and must be submitted to TMHP.

5.4.2Reimbursement Reductions

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement and the federal matching percentage.

6 Psychiatric Services for Hospitals

Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid. Admissions must be medically necessary and are subject to Texas Medicaid’s retrospective utilization review (UR) requirements. The UR requirements are applicable regardless of the hospital’s designation of a unit as a psychiatric unit versus a medical or surgical unit.

Clients who are 20 years of age and younger may be admitted to a freestanding psychiatric facility or a state psychiatric facility. Clients who are 21 years of age and older may be admitted only to an acute care facility. Providers should use the most appropriate revenue code when billing for inpatient psychiatric services in an acute care facility. A certification of need must be completed and placed in the client’s medical record within 14 days of the admission or once the client becomes Medicaid-eligible while in the facility.

Inpatient psychiatric treatment is a benefit of Texas Medicaid if all the following apply:

The client has a psychiatric condition that requires inpatient treatment.

The inpatient treatment is directed by a psychiatrist.

The inpatient treatment is provided in a nationally accredited facility or hospital.

The provider is enrolled in Texas Medicaid.

Clients of all ages may be admitted to an acute care facility. Inpatient admissions for the single diagnosis of chemical dependency or abuse (such as alcohol, opioids, barbiturates, and amphetamines) without an accompanying medical complication are not benefits of Texas Medicaid. Additionally, admissions for chronic diagnoses such as intellectual disability, organic brain syndrome, or chemical dependency or abuse are not covered benefits for acute care hospitals without an accompanying medical complication or medical condition. The UB-04 CMS-1450 paper claim form must indicate all relevant diagnoses that necessitate the inpatient stay.

Supporting documentation (certification of need) must be documented in the client’s medical record. This documentation must be maintained by each facility for a minimum of five years and be readily available for review when requested by HHSC or its designee.

Additional coverage through the Comprehensive Care Program (CCP) may be allowed for Medicaid-eligible clients who are 20 years of age and younger. Providers should use revenue code 124 when billing for inpatient psychiatric services in freestanding and state psychiatric facilities.

Refer to:  Subsection 2.16, “Inpatient Psychiatric Hospital or Facility (Freestanding) (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

6.1Prior Authorization Requirements

Prior authorization is not required for fee-for-service clients who are admitted to psychiatric units in acute care hospitals. Out-of-network admissions require notification within the next business day and submission of clinical information to determine appropriateness for transfer to a contracted facility.

Prior authorization is not required for initial admission to freestanding psychiatric facilities or state psychiatric hospitals for clients who are 20 years of age and younger for a maximum of five days based on Medicaid eligibility and documentation of medical necessity. Extended stay requests beyond the initial 5 days require prior authorization.

Refer to:  Subsection 2.17.3, “Prior Authorization and Documentation Requirements” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about inpatient psychiatric services.

6.2Documentation Requirements

Documentation of medical necessity for inpatient psychiatric care must specifically address the following issues:

Why the ambulatory care resources in the community cannot meet the treatment needs of the client.

Why inpatient psychiatric treatment under the care of a psychiatrist is required to treat the client’s acute episode.

How the services can reasonably be expected to improve the client’s condition or prevent further regression of the client’s condition in a proximate time period.

6.3Inpatient Hospital Discharge

Procedure codes 99238 and 99239 must be submitted when billing for a hospital discharge.

7 Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT is a comprehensive, public health approach to the delivery of early intervention and treatment services for clients who are 10 years of age and older and who have alcohol or substance use disorders or are at risk of developing such disorders. Substance abuse includes, but is not limited to, the abuse of alcohol and the abuse of, improper use of, or dependency on illegal or legal drugs. SBIRT is used for intervention directed to individual clients and not for group intervention.

SBIRT services can be provided by physicians, registered nurses, advanced practice nurses, physician assistants, psychologists, licensed clinical social workers, licensed professional counselors, certified nurse midwives, outpatient hospitals, federally qualified health centers (FQHCs), and rural health clinics (RHCs). Non-licensed providers may deliver SBIRT under the supervision of a licensed provider if such supervision is within the scope of practice for that licensed provider. The same SBIRT training require­ments apply to non-licensed providers.

Clients may have a maximum of two screening only sessions per rolling year, and up to four combined screening and brief intervention sessions per rolling year. Providers must refer the client to treatment if the screening results reveal severe risk of alcohol or substance abuse.

Refer to:  Section 8, “Substance Use Disorder (SUD) Services (Abuse and Dependence)” in this handbook for additional information on SUD treatment.

7.1SBIRT Training

Providers that perform SBIRT must be trained in the correct practice of this method and will be required to complete at least four hours of training. Proof of completion of SBIRT training must be maintained in an accessible manner at the provider’s place of service.

Information regarding available trainings and standardized screening tools can be found through the Substance Abuse and Mental Health Services Administration.

7.2Screening

Screening clients for problems related to alcohol or substance use identifies the individual’s level of risk and determines the appropriate level of intervention indicated for the individual. Providers must explain the screening results to the client, and if the results are positive, be prepared to subsequently deliver, or delegate to another provider, brief intervention services. Screening must be conducted using a standardized screening tool. Standardized tools that may be used include, but are not limited to, the following:

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

Drug Abuse Screening Test (DAST)

Alcohol Use Disorders Identification Test (AUDIT)

Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire

Car, Relax, Alone, Forget, Family or Friends, Trouble (CRAFFT) questionnaire

Binge drinking questionnaire

Results obtained through blood alcohol content (BAC) or through toxicology screening may also be used to screen for alcohol or substance abuse risk.

7.3Brief Intervention

Brief intervention is performed following a positive screen or a finding of at least a mild to moderate risk for alcohol or substance abuse. During the session, brief intervention involves motivational interviewing techniques (such as the Brief Negotiated Interview) that is focused on raising the client’s awareness of his or her alcohol or substance use and its consequences. The session is also focused on motivating the client toward behavioral change.

Subsequent screening and brief intervention sessions within the allowable annual limitations may be indicated to assess for behavior change and further explore a client’s readiness to make behavioral changes related to their alcohol or substance use.

Note:Providers may choose to schedule multiple screening and brief intervention sessions in a rolling year in order to provide ongoing support to a client at risk for substance abuse who is receptive to behavior change.

7.4Referral to Treatment

If the provider determines that the client is in need of more extensive treatment or has a severe risk for alcohol or substance abuse, the client must be referred to an appropriate substance use treatment provider.

Referral to more extensive treatment is a proactive process that facilitates access to care for clients who require a more extensive level of service than SBIRT provides. Referral is an essential component of the SBIRT intervention because it ensures that all clients who are screened have access to the appropriate level of care.

Note:If the client is currently under the care of a behavioral health provider, the client must be referred back to that provider.

7.5Reimbursement and Limitations

SBIRT is limited to clients who are 10 years of age and older.

SBIRT is limited to up to two screening sessions per rolling year. A screening that results in a negative result does not require a brief intervention. In these instances procedure code H0049 should be used. A provider may re-screen a client within the same rolling year to determine whether a client’s substance use behavior has changed.

Procedure code 99408 should be used when a brief intervention follows an SBIRT screening. Procedure code 99408 is limited to once per day. SBIRT is limited to four sessions per rolling year when it consti­tutes a screening followed by a brief intervention.

If a client requires more than four combined screening and brief intervention sessions per rolling year, the client must be referred for substance abuse treatment.

SBIRT is not reimbursable to providers (whether licensed or non-licensed) who have not completed the required number of training hours in SBIRT methodology.

Procedure codes 99408 and H0049 will be denied if billed for the same date of service as any of the following procedure codes:

Procedure Codes

90791

90792

90832

90833

90834

90836

90837

90838

90847

90853

90865

90870

96101

96116

96118

Procedure codes 99408 and H0049 cannot both be billed on the same date.

Physicians and other qualified health care professionals that bill an Evaluation and Management (E/M) code for a visit where SBIRT occurred must use modifier 25 to identify a significant, separately identi­fiable E/M service rendered by the same provider on the same date of service.

Note:FQHCs and RHCs should submit claims using SBIRT procedure codes for informational purposes only.

7.6Documentation Requirements

Client record documentation must support medical necessity for the SBIRT services provided and must be maintained by the SBIRT provider and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation for screening must include the following:

The provider who performed the SBIRT screening

Screening results from a standardized screening tool or laboratory results such as BAC, toxicology screen, or other measures showing risk for alcohol or substance abuse and the specific screening tool used.

Documentation for SBIRT brief intervention sessions must include a client-centered plan for the delivery of medically necessary services that supports the use of procedure code 99408. The plan must include all of the following:

The provider who performed the SBIRT brief intervention, if different from the provider who screened the client

Start and stop time of the session, or the total face-to-face time spent providing SBIRT services to the client

Goals established

Specific strategies to achieve the goals

The client’s support system such as family members, a legal guardian, or friends.

Note:If subsequent sessions are indicated, the provider who performed the SBIRT session must document that a follow up SBIRT appointment was made and with whom, or document another mechanism established to reassess progress

The name, address, and phone number of the provider that the patient has been referred to for substance use disorder treatment

Services are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the services provided.

7.7Claims Filing and Reimbursement

SBIRT services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attach­ments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Texas Medicaid rates for Hospitals are calculated according to 1 TAC §355.8061.

According to 1 TAC §355.8091, the Medicaid rate for LCSWs, LMFTs, and LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085.

The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8081 and §355.8085.

Texas Medicaid rates for physicians and certain other practitioners are calculated in accordance with TAC §355.8085.

Texas Medicaid rates for Nurse Practitioners and Clinical Nurse Specialists are calculated in accordance with TAC §355.8281.

According to 1 TAC §355.8093, the Medicaid rate for PAs is 92 percent of the rate paid to a physician (MD or DO) for the same professional service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. Services performed by a PA and billed under a physician’s or RHC’s provider identifier are reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM) for physician services.

Note:For more information about Texas Medicaid rates for the provider types above, refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

8 Substance Use Disorder (SUD) Services (Abuse and Dependence)

8.1Overview

Treatment for SUD is a benefit of Texas Medicaid. SUD treatment services are age appropriate medical and psychotherapeutic services designed to treat a client’s substance use disorder and restore function. Services and provider requirements associated with this benefit are found in Texas Department of Insurance (TDI) regulations (28 TAC, part 1 subchapter 3 subcategory HH) and TAC §448.902 and must be strictly followed. Medical necessity for substance abuse services will be determined based on the TDI regulations and nationally recognized standards such as those from the American Society of Addiction Medicine (ASAM) or the Center for Substance Abuse Treatment (CSAT).

The following SUD services are a benefit of Texas Medicaid:

Assessment by a CDTF for admission into a SUD treatment program.

Detoxification services when provided in a general acute care hospital, residential, or ambulatory CDTF setting.

Note:Crisis intervention is not a component of detoxification. Crisis intervention for a mental health condition may be provided as needed when the service is medically necessary and the clinical criteria for psychiatric care are met.

Residential SUD treatment services.

Ambulatory SUD treatment services provided by a CDTF.

Medication-assisted therapy (MAT) in an outpatient setting.

SUD services provided by a CDTF are limited to those provided by facilities that are licensed and regulated by DSHS to provide SUD services within the scope of that facility’s DSHS license.

Intensive outpatient (IOP) services are ambulatory outpatient services that are provided by CDTF providers.

IOP services are benefits of Texas Medicaid. IOP services are available to clients of all ages and include a maximum of 135 hours of group counseling and 26 hours of individual counseling per calendar year.

The modifiers listed in the following table must be used in the appropriate combination for SUD services to identify the services performed:

Modifiers

Description

HF

Use to identify a substance abuse program in a facility

HG

Use to identify an opioid addiction treatment program

UA

Use to identify supervised administered dosing

U1

Use to identify unsupervised dosing

8.2Enrollment

8.2.1CDTFs

Only CDTFs licensed by DSHS are eligible to enroll and participate in Texas Medicaid. Each facility must submit a copy of its DSHS license with the enrollment packet. Facilities that are maintained or operated by the federal government or directly operated by the state of Texas are exempt from the licensing requirements.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for information on the provider enrollment process.

8.3Assessment

Clients must be assessed by a Medicaid-enrolled CDTF for treatment services to begin. Clients who are in fee-for-service Medicaid can obtain their assessment from any Medicaid-enrolled CDTF.

CDTF assessment must be performed by a qualified credentialed counselor (QCC) (as defined by the DSHS licensure standard) to determine the severity of a client’s SUD and identify their treatment needs. Assessments are limited to once per episode of care. An assessment must be billed with procedure code H0001 and modifier HF.

Documentation of the QCC assessment must be maintained in the client’s medical record.

8.4Opioid Treatment Program (OTP)

SUD services that are provided in an opioid treatment program (OTP) are a benefit of Texas Medicaid. OTP services are medication-assisted therapy services that threat patients addicted to heroin or other opiates.

OTPs are required to follow guidelines established by the following:

Code of Federal Regulations Title 42 Part 8.

Controlled Substances Act section 303(g), United States Code Title 21 section 823(g).

Substance Abuse and Mental Health Services Administration (SAMHSA).

Detoxification in an OTP is the gradual tapering of methadone or buprenorphine doses, which results in the eventual cessation of these drugs. Claims for OTP-based detoxification are submitted as medication-assisted therapy using one of the following procedure codes:

Procedure code H0020

Procedure code H2010 with modifier HF or HG

An OTP must have current procedures to ensure that clients are admitted to detoxification treatment by qualified personnel, such as a program physician, who uses established diagnostic criteria to determine that the treatment is appropriate for each client. A client may not be admitted for more than two detox­ification episodes in one rolling year. Clients with two or more unsuccessful detoxification episodes with in a 12-month period must be assessed by the OTP physician for other forms of treatment. An assessment for the opioid addiction treatment program must be billed with procedure code H0001 and modifier HG.

Note:There is no billing provider type in Texas Medicaid for an OTP or narcotic treatment clinic. OTPs must either submit claims using the physicians’ provider identifier, or as a DSHS-licensed chemical dependency treatment facility (CDTF).

8.5Detoxification Services

Detoxification services are a set of interventions aimed at managing acute physiological substance dependence. According to TAC §448.902 detoxification services include, but are not limited to, the following components:

Evaluation

Monitoring

Medication

Daily interactions

All clients who are admitted to a detoxification program must meet the current DSM criteria for physi­ological substance dependence and must meet the admission requirements based on a nationally-recognized standard.

8.5.1Ambulatory (Outpatient) Detoxification Services

Ambulatory (outpatient) detoxification is appropriate when the client’s medical needs do not require close monitoring.

Ambulatory (outpatient) detoxification is not a stand-alone service and must be provided in conjunction with ambulatory (outpatient) substance abuse treatment services.

Ambulatory (outpatient) detoxification services must be billed with procedure codes H0016, H0050, or S9445 and modifier HF.

8.5.2Residential Detoxification Services

Residential detoxification is appropriate when the client’s medical needs do not warrant an acute inpatient hospital admission, but the severity of the anticipated withdrawal requires close monitoring.

The assessment by a CDTF is required before services begin; however, if the client’s condition is such that a comprehensive assessment cannot be completed, it is appropriate to conduct an abbreviated assessment on admission. The full assessment must be completed within 24 hours of admission.

Residential detoxification services must be billed with procedure codes H0012, H0031, H0047, S9445, or T1007 and modifier HF.

Medically-supervised hospital inpatient detoxification is appropriate when one of the following criteria is met:

The client has complex medical needs or complicated comorbid conditions that necessitate hospi­talization for stabilization.

The services that are provided to a client are incidental to other medical services that are provided as a component of an acute care hospital stay.

8.6Treatment Services

Treatment services may be provided by a CDTF in a residential facility or as an ambulatory (outpatient) service.

Note:MAT is recognized as a separately identifiable service in the ambulatory (outpatient) setting and may be provided during the treatment period in conjunction with other ambulatory (outpatient) treatment services.

8.6.1Residential Treatment Services

Residential treatment services include counseling and psycho-education and must be billed with procedure codes H0047 and H2035 and modifier HF.

8.6.2Ambulatory (Outpatient) Treatment Services

Ambulatory (outpatient) treatment services must be billed with procedure codes H0004 or H0005 and modifier HF.

Procedure codes H0004 and H0005 are limited to the following diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)

F1010

F1011

F10120

F10129

F10159

F10188

F1019

F1020

F1021

F10220

F10229

F10230

F10232

F10239

F10259

F10281

F10288

F1029

F10920

F10929

F10959

F10988

F1099

F1110

F1111

F11120

F11159

F11181

F11182

F11188

F1119

F1120

F1121

F11220

F11222

F11229

F1123

F11259

F11281

F11282

F11288

F1129

F11920

F11922

F11929

F1193

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12122

F12129

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12222

F12229

F12259

F12280

F12288

F1229

F12920

F12922

F12929

F12959

F12980

F12988

F1299

F1311

F13120

F13129

F13159

F13180

F13181

F13182

F13188

F1320

F1321

F13220

F13229

F13230

F13232

F13239

F13259

F13280

F13281

F13282

F13288

F13920

F13929

F13930

F13932

F13939

F13959

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14122

F14129

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14222

F14229

F1423

F14259

F14280

F14281

F14282

F14288

F1429

F14920

F14922

F14929

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15122

F15129

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15222

F15229

F1523

F15259

F15280

F15281

F15282

F15288

F1529

F15920

F15922

F15929

F1593

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16122

F16129

F16159

F16180

F16183

F16188

F1619

F1620

F16220

F16229

F16259

F16280

F16283

F16288

F1629

F16920

F16929

F16959

F16980

F16983

F16988

F1699

F17208

F17209

F17218

F17219

F17228

F17229

F17298

F17299

F1810

F1811

F18120

F18129

F18159

F18180

F18188

F1819

F1820

F1821

F18220

F18229

F18259

F18280

F18288

F1829

F18920

F18929

F18959

F18980

F18988

F1899

F1910

F1911

F19120

F19122

F19129

F19159

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F19222

F19229

F19230

F19232

F19239

F19259

F19280

F19281

F19282

F19288

F1929

F19920

F19922

F19929

F19930

F19932

F19939

F19959

F19980

F19981

F19982

F19988

F1999

F551

F553

8.6.3Physician Services

Physician services may be reimbursed separately using the appropriate E/M procedure codes.

8.7Medication Assisted Therapy (MAT)

MAT may be a benefit of Texas Medicaid when using a drug or biological recognized in the treatment of SUD and provided as a component of a comprehensive treatment program per TAC §448.902, or as a conjunctive treatment regimen for individuals addicted to abusable substances who meet the current DSM criteria for a SUD.

MAT is considered part of detoxification (residential and ambulatory outpatient) and residential treatment except for the following:

Pregnant women with an opioid addiction

Clients in current treatment for an opioid addiction who also have a substance addiction to another substance other than opioids

Documentation requirements supporting the medical necessity for MAT must be maintained in the client’s medical record according to the requirements in Federal Regulation 42 CFR §8. MAT must be performed by a physician; however, the physician may delegate this responsibility to other licensed personnel under his supervision. Documentation must include the name and title of the physician performing or delegating other MAT services. The client’s medical records are subject to retrospective review.

Clients who are 17 years of age and younger may not be admitted to a narcotic maintenance program unless a parent, legal guardian, or responsible adult designated by the relevant state authority consents in writing to such treatment. To be eligible for narcotic maintenance treatment, clients who are 17 years of age and younger must have had two documented attempts at short-term detoxification or drug-free (non-opioid) treatment within a 12-month period. A waiting period of no less than seven days is required between the first and the second short-term detoxification treatment.

Every exception to the general age requirement must be clinically justified and documented by a QCC. The facility must maintain the supporting documentation, including the QCC admission approval in the client’s medical record.

MAT for the treatment of opioid addiction must comply with the requirements in Federal Regulation 42 CFR §8.

Refer to:  Subsection 8.10.3, “MAT Services” in this handbook for more information on claims filing.

8.8Prior Authorization

The following services do not require prior authorization:

Assessment

Ambulatory (outpatient) treatment services

MAT

Inpatient hospital detoxification for fee-for-service clients in a general acute care facility

The following services require prior authorization:

Ambulatory (outpatient) detoxification services

Ambulatory (outpatient) treatment for clients who are 20 years of age and younger and who exceed the benefit limitation of 135 hours of group service and 26 hours of individual services per calendar year

Residential detoxification services

Residential treatment services

Providers must submit the appropriate prior authorization request form for the initial or continuation of ambulatory (outpatient) or residential detoxification treatment and residential treatment services. A physician (who does not need to be affiliated with the CDTF) must complete and sign the Ambulatory (Outpatient) Substance Abuse Extension Request Form. A QCC (as defined by the DSHS licensure standard) must complete and sign the other prior authorization request forms.

Providers must submit one of the following forms to obtain prior authorization:

Ambulatory (Outpatient) Detoxification Authorization Request Form

Ambulatory (Outpatient) Substance Abuse Counseling Extension Request Form

Residential Detoxification Authorization Request Form

Residential Substance Abuse Treatment Authorization Request Form

Prior authorization for ambulatory and residential detoxification services will not be issued for clients who are 12 years of age and younger unless the request is accompanied by a waiver from DSHS Regulatory and Licensing Division.

Prior authorization will be considered for the least restrictive environment appropriate to the client’s medical need as determined in the client’s plan of care (POC), based on national standards.

Prior authorization requests for clients who are 20 years of age and younger for services beyond the limitations outlined in this section, may be considered with documentation from a physician (who does not need to be affiliated with the CDTF) supporting the medical necessity for continuation of the treatment.

8.8.1Prior Authorization for Fee-for-Service Clients

Prior authorization requests for fee-for-service clients may be submitted to the TMHP Prior Authori­zation Unit online at www.tmhp.com, by fax at 1-512-514-4211, or by mail to:

Texas Medicaid & Healthcare Partnership
TMHP Prior Authorization Department
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727

Providers may contact the TMHP Prior Authorization Unit by telephone at 1-800-213-8877, Option 2, to obtain information about substance use disorder benefits, the prior authorization process, or the status of a prior authorization request. Prior authorization for substance use disorder services cannot be obtained through this line.

Prior authorization for ambulatory (outpatient) detoxification, residential treatment, or residential detoxification services may be considered when requested within three business days after the date of admission.

8.8.2Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment Services

Ambulatory (outpatient) detoxification services may be prior authorized for up to 21 days. The level of service and number of days that are prior authorized will be based on the substances that are abused, level of intoxication and withdrawal potential, and the client’s medical needs.

8.8.2.1Admission Criteria for Ambulatory (Outpatient) Detoxification Treatment Services

To be considered eligible for treatment for ambulatory detoxification services, the client must meet the following conditions:

Chemical Substance Withdrawal

The client must meet all of the following criteria with regard to chemical substance withdrawal:

The client is expected to have a stable withdrawal from alcohol or drugs.

The diagnosis must meet the criteria for the definition of substance (chemical) dependence, as detailed in the most current revision of the ICD-10-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Medical Functioning

The client must meet all of the following criteria with regard to medical functioning:

No history of recent seizures or past history of seizures during withdrawal.

No clinical evidence of altered mental state as manifested by disorientation to self, alcoholic hallu­cinations, toxic psychosis, or altered level of consciousness (clinically significant obtundation, stupor, or coma).

The symptoms are due to withdrawal and not due to a general medical condition. Absence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).

Stable vital signs as interpreted by a physician. The client must also be without a previous history of complications from acute chemical substance withdrawal and judged to be free of a health risk as determined by a physician.

No evidence of a coexisting serious injury or systemic illness either newly discovered or progressive in nature.

Absence of serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia, or hypotension.

Clinical condition that allows for a comprehensive and satisfactory assessment.

Family, Social, or Academic Dysfunction

The client must meet at least one of the following criteria with regard to family, social, or academic dysfunction:

The client’s social system and significant others are supportive of recovery to the extent that the client can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the client’s addiction.

The client’s family or significant others are willing to participate in the ambulatory (outpatient) detoxification treatment program.

The client may or may not have a primary or social support system to assist with immediate recovery, but the client has the social skills to obtain such a support system or to become involved in a self-help fellowship.

The client does not live in an environment where licit or illicit mood altering substances are being used. A client living in an environment where licit or illicit mood altering substances are being used may not be a candidate for this level of care.

Emotional and Behavioral Status

The client must meet all of the following criteria with regard to emotional and behavioral status:

Client is coherent, rational, and oriented for treatment.

The mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented, and the client is able to participate in the ambulatory (outpatient) detoxifi­cation treatment process.

Documentation exists in the medical record that the client expresses an interest to work toward ambulatory (outpatient) detoxification treatment goals.

Client has no neuropsychiatric condition that places the client at imminent risk of harming self or others (e.g. pathological intoxication or alcohol idiosyncratic intoxication).

Client has no neurological, psychological, or uncontrolled behavior that places the client at imminent risk of harming self or others (depression, anguish, mood fluctuations, overreactions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, or anxiety).

Client has no documented DSM condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the client.

The client has no mental confusion or fluctuating orientation.

Chemical Substance Use

The client must meet the criteria in at least one of the following conditions with regard to recent chemical substance use:

The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

The client is motivated to stop using alcohol or drugs and is in need of a supportive, structured treatment program to facilitate withdrawal from chemical substances.

8.8.2.2Continued Stay Criteria for Ambulatory (Outpatient) Detoxification Treatment Services

A client is considered eligible for continued stay in the ambulatory (outpatient) detoxification treatment service when the client meets at least one of the conditions for either chemical substance withdrawal or psychiatric or medical complications. Requests for continuation of services must be received on or before the last date authorized or denied. The prior authorization unit will notify the provider by fax or electronic portal. If the date of the prior authorization unit determination letter is on or after the last date authorized or denied, the request for continuation of services is due by 5 p.m. of the next business day. Documentation in the client’s medical record must support either Chemical Substance Withdrawal or Psychiatric or Medical Complications.

Chemical Substance Withdrawal

The client must meet at least one of the following conditions with regard to chemical substance withdrawal complications:

The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by psychological and physical cravings.

The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by significant drug levels.

Psychiatric or Medical Complications

The client must meet both of the following psychiatric or medical complication conditions:

The intervening medical or psychiatric event was serious enough to interrupt the ambulatory (outpatient) detoxification treatment.

Evidence that the client is progressing in treatment again.

8.8.3Prior Authorization for Residential Detoxification Treatment Services

Detoxification services may be prior authorized for up to 21 days. The level of service and number of prior authorized days will be based on the substances that are abused, level of intoxication and withdrawal potential, and the client’s medical needs.

Requests for detoxification services for clients who are 20 years of age and younger and who need more than 21 days of residential detoxification require Medical Director review with documentation of medical necessity from a physician who is familiar with the client.

8.8.3.1Admission Criteria for Residential Detoxification Treatment Services

Clients are eligible for admission to a residential detoxification service when they have failed two previous individual treatment episodes of ambulatory (outpatient) detoxifications or when they have a diagnosis that meets the criteria for the definition of chemical dependence, as detailed in either the most current revision of the ICD-10-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners.

In addition, the client must meet at least one of the following criteria for chemical substance withdrawal, major medical complication, or major psychiatric illness for admission to residential treatment for detoxification:

Chemical Substance Withdrawal

Impaired neurological functions as evidenced by:

Extreme depression (e.g., suicidal).

Altered mental state with or without delirium as manifested by disorientation to self; alcoholic hallucinosis, toxic psychosis, altered level of consciousness, as manifested by clinically significant obtundation, stupor, or coma.

History of recent seizures or past history of seizures on withdrawal.

The presence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb incoordination).

Unstable vital signs combined with a history of past acute withdrawal syndromes that are inter­preted by a physician to be indication of acute alcohol or drug withdrawal.

Evidence of coexisting serious injury or systemic illness, newly discovered or progressive.

Clinical condition (e.g., agitation, intoxication, or confusion) that prevents satisfactory assessment of the above conditions and indicates placement in residential detoxification service may be justified.

Neuropsychiatric changes of such severity and nature that they put the client at imminent risk of harming self or others (e.g., pathological intoxication or alcohol idiosyncratic intoxication, etc.).

Serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia, or hypotension.

Major Medical Complications

For major medical complications, the client must present a documented condition or disorder that, in combination with alcohol or drug use, presents a determined health risk (e.g., gastrointestinal bleeding, gastritis, severe anemia, uncontrolled diabetes mellitus, hepatitis, malnutrition, cardiac disease, hypertension).

Major Psychiatric Illness

The client must meet at least one of the following conditions with regard to major psychiatric illness:

Documented DSM condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the individual.

Severe neurological and psychological symptoms: (e.g., anguish, mood fluctuations, overreactions to stress, lowered stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, extreme negative emotions, or extreme anxiety).

Danger to others or homicidal.

Uncontrolled behavior that endangers self or others, or documented neuropsychiatric changes of a severity and nature that place the individual at imminent risk of harming self or others.

Mental confusion or fluctuating orientation.

8.8.3.2Continued Stay Criteria for Residential Detoxification Treatment Services

Eligibility for continued stay for residential detoxification services is based on the client meeting at least one of the criteria for chemical substance withdrawal, major medical complications, or major psychiatric complications.

Chemical Substance Withdrawal

The client must exhibit one of the following conditions with regard to chemical substance withdrawal complications:

Incomplete medically stable withdrawal from alcohol or drugs, as evidenced by documentation of at least one of the following conditions:

Unstable vital signs

Continued disorientation

Abnormal laboratory findings related to chemical dependency

Continued cognitive deficit related to withdrawal so that the client is unable to recognize alcohol or drug use as a problem

Laboratory finding that, in the judgment of a physician, indicates that a drug has not sufficiently cleared the client’s system

Major Medical Complications

For major medical complications, the client must have documentation in the medical record that indicates that a medical condition or disorder (e.g., uncontrolled diabetes mellitus) continues to present a health risk and is being actively treated.

Major Psychiatric Complications

The client must meet at least one of the following with regard to major psychiatric complications:

Documentation in the medical record that a DSM psychiatric condition or disorder that, in combi­nation with alcohol or drug use, continues to present a major health risk, is actively being treated.

Documentation in the medical record that severe neurological or psychological symptoms have not been satisfactorily reduced but are actively being treated.

8.8.4Prior Authorization for Residential Treatment Services

Residential treatment may be prior authorized for up to 35 days per episode of care, with a maximum of two episodes of care per rolling six-month period, and four episodes of care per rolling year.

8.8.4.1Admission Criteria for Residential Treatment Services

The diagnosis must meet the criteria for the definition of chemical dependence, as detailed in the most current revision of the ICD-10-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Clients must meet the following conditions in order to receive treatment in a residential treatment service program:

Medical Functioning

The following must be present with regard to medical functioning:

Documented medical assessment following admission (except in instances where the client is being referred from an inpatient service) indicates that the client is medically stable and not in acute withdrawal.

The client is not bed-confined and has no medical complications that would hamper participation in the residential service.

Family, Social, or Academic Dysfunction and Logistic Impairments

At least one of the following must be present with regard to family, social, or academic dysfunction and logistic impairments:

The client manifests severe social isolation or withdrawal from social contacts.

The client lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed (e.g., a chaotic family dominated by interpersonal conflict, which undermines client’s efforts to change).

Client’s family or significant others are opposed to the client’s treatment efforts and are not willing to participate in the treatment process.

Family members or significant others living with the client manifest current chemical dependence disorders and are likely to undermine treatment.

Logistic impairments (e.g., distance from treatment facility or mobility limitations) preclude partic­ipation in a partial hospitalization or ambulatory (outpatient) treatment service.

Emotional and Behavioral Status

The client must meet all three of the following criteria with regard to emotional and behavioral status:

Client is coherent, rational, and oriented for treatment.

Mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented and participate in rehabilitation or the treatment process.

The medical record contains documentation that with continued treatment the client will be able to improve or internalize the client’s motivation toward recovery within the recommended length of stay time frames (e.g., becoming less defensive, verbalizing, and working on alcohol or drug related issues). Interventions, treatment goals, or contracts are in place to help the client deal with or confront the blocks to treatment (e.g., family intervention or employee counseling confrontation).

Chemical Substance Use

The client must meet at least one of the following criteria with regard to chemical substance use:

The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

Virtually all of the client’s daily activities revolve around obtaining, using, or recuperating from the effects of chemical substances, and the client requires a secured environment to control the client’s access to chemical substances.

8.8.4.2Residential Treatment Services for Adolescents

Clients who are 13 through 17 years of age must meet all above conditions and the following conditions in order to receive treatment in an adolescent residential treatment service program:

At the maturation level, the adolescent client must meet both of the following criteria:

The client is assessed as manifesting physical maturation at least in middle adolescent range (i.e., post-pubescent).

The history of the adolescent reflects cognitive development of at least 11 years of age.

The adolescent client must display at least one of the following with regard to developmental status:

Documented history of inability to function within the expected age norms despite normal cognitive and physical maturation (e.g., refusal to interact with family members, overt prosti­tution, felony, or other criminal charges).

A recent history of moderate to severe conduct disorder, as defined in the Diagnostic and Statis­tical Manual for Professional Practitioners, or impulsive disregard for social norms and rights of others.

Documented difficulty in meeting developmental expectations in a major area of functioning (e.g., social, academic, or psychosexual) to an extent that interferes with the capacity to remain behaviorally stable.

8.8.4.3Continued Stay Criteria for Residential Treatment Services

At least one of the following conditions must be present for continued stay in a residential treatment program:

Chemical Dependency Rehabilitation or Treatment Complications

The client recognizes or identifies with the severity of the alcohol or drug problem but demon­strates minimal insight into the client’s defeating the use of alcohol or drugs. However, documentation in the medical record indicates that the client is progressing in treatment; or

The client identifies with the severity of the alcohol or drug problem and manifests insight into the client’s personal relationship with mood-altering chemicals, yet does not demonstrate behaviors that indicate the development of problem-solving skills that are necessary to cope with the problem; and

The client would predictably relapse if moved to a lesser level of care.

Psychiatric or Medical Complications:

Documentation in the medical record indicates an intervening medical or psychiatric event that was serious enough to interrupt rehabilitation or treatment, but the client is again progressing in treatment.

Documentation in the medical record indicates that the client is being held pending an immediate transfer to a psychiatric, acute medical service, or inpatient detoxification alcohol or drug service.

8.8.5Prior Authorization for Ambulatory (Outpatient) Treatment Services for Clients Who Are 20 Years of Age and Younger

Prior authorization for ambulatory (outpatient) treatment services beyond the annual limitation of 135 hours of group services and 26 hours of individual services per calendar year, may be considered for clients who are 20 years of age and younger with documentation from a physician (who does not need to be affiliated with the CDTF) of the supporting medical necessity for continued treatment services.

Requests must be submitted before providing the extended services. The documentation must include the following information:

The client is meeting treatment goals.

The client demonstrates insight and understanding into relationship with mood altering chemicals, but continues to present with issues addressing the life functions of work, social, or primary relationships without the use of mood-altering chemicals.

And one of the following:

Although physically abstinent from chemical substance use, the client remains mentally preoc­cupied with such use to the extent that the client is unable adequately to address primary relationships or social or work tasks. Nevertheless, there are indications that, with continued treatment, the client will effectively address these issues.

Although other psychiatric or medical complications exist that affect the client’s treatment, documentation exists that the client continues to show treatment progress and that there is evidence to support the benefits of continued treatment.

8.9Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including SUD services.

All SUD services are subject to retrospective review. All documentation must be maintained in the client’s medical record and be made available upon request.

8.10Reimbursement and Limitations

8.10.1Detoxification Services

Inpatient detoxification is reimbursed by the reimbursement methodology specific to the inpatient hospital. Separate reimbursement may be provided for physician services performed during an inpatient stay.

Residential detoxification and treatment services are considered outpatient services for the purposes of reimbursement and should be billed accordingly.

Residential detoxification (procedure codes H0012, H0031, S9445, and T1007) are limited to once per day.

Residential detoxification (procedure codes H0031, H0047, S9445, or T1007) will be denied if billed without procedure code H0012.

Room and board for residential detoxification and treatment (procedure code H0047) is limited to once per date of service. Procedure code H0047 is reimbursed for clients who are 21 years of age and older as an access-based fee, and as an informational detail for clients who are 20 years of age and younger.

Ambulatory (outpatient) detoxification (procedure codes H0016, H0050, and S9445) are limited to once per day and may be reimbursed on the same date of service as ambulatory (outpatient) SUD treatment by the same or different provider when medically necessary and identified in the client’s treatment plan. For services rendered in the CDTF setting, providers must use the HF modifier.

Ambulatory (outpatient) detoxification (procedure codes H0050 and S9445) will be denied if billed without procedure code H0016.

Separate reimbursement may be provided for physician services during a residential stay.

8.10.2Treatment Services

Ambulatory (outpatient) treatment (procedure codes H0004 and H0005) is reimbursed at a time-based rate.

Ambulatory (outpatient) treatment services are limited to 135 hours of group counseling and 26 hours of individual counseling per calendar year when provided by a CDTF.

Residential treatment services (procedure code H2035) are limited to one per day and are allowed up to a maximum of 35 days.

Ambulatory (outpatient) treatment (procedure codes H0004 and H0005) will be denied if billed on the same date of service as residential detoxification (procedure codes H0012, H0031, H0047, and T1007) or residential treatment (procedure code H2035).

Procedure code H0047 will be denied if billed without procedure code H2035.

8.10.3MAT Services

MAT may be considered for reimbursement on appeal on the same date of service as residential detox­ification, ambulatory (outpatient) detoxification, or residential treatment services. For the claim to be considered, providers must:

Submit supporting documentation that indicates one of the following:

The client is a pregnant woman with an opioid addiction.

The client is in current MAT treatment for an opioid addiction and is also receiving residential services for a substance other than opioids.

Submit one of the following opioid diagnosis codes on the claim:

Diagnosis Codes

Description

F1120, F1121, F11220, F11221, F11222, F11229, F1123, F1124, F11259, F11281, F11282, F11288, F1129

Opioid type dependence

F1821, F1920, F1921

Combination of opioid type drug

F1110

Opioid abuse

Submit one of each of the following non-opioid and pregnancy diagnosis codes on the claim:

Diagnosis Codes   

Description

F1020, F1021

Other and unspecified alcohol dependence

F1320, F1321

Sedative, hypnotic or anxiolytic dependence

F1420, F1421

Cocaine dependence

F1520, F1521

Amphetamine and other psychostimulant dependence

F1620, F1621

Hallucinogen dependence

F1620, F1820, F1821, F1920, F1921

Other or unspecified drug dependence

F15120, F15129, F15220, F15229, F15920, F15929, F1610, F1810, F1890, F1910, F551, F553

Other, mixed, or unspecified drug abuse

O99320, O99321, O99322, O99323, O99325

Pregnancy-related diagnoses

Claims billed for MAT must include the client’s substance use disorder diagnosis.

Procedure codes H0020 or H2010 will be denied if a claim is submitted for the same date of service as procedure codes H0012, H0016, H0031, H0047, H0050, H2035, S9445, or T1007.

Methadone administration (procedure code H0020) for opioid addiction must be submitted with the following modifiers:

When methadone is administered with supervision in a facility the provider must submit claims using the UA modifier to indicate the facility administered doses

When methadone is dispensed without supervision as a take home dose the provider must submit claims using the U1 modifier to indicate take home doses

Methadone administration (procedure code H0020) with modifier U1 for unsupervised take home doses must be submitted on the same claim and with the same date of service as methadone adminis­tration (procedure code H0020) with modifier UA for supervised facility doses or the take home doses will be denied.

MAT provided in an ambulatory (outpatient) setting (procedure code H0020) is limited to once per date of service, except for unsupervised take home doses (U1 modifier), by any provider and is reimbursed at a fixed daily rate. Reimbursement for procedure code H0020 with modifier U1 is limited to a quantity of 30 per 30 days.

Methadone administration (procedure code H0020) submitted without a modifier will be denied.

Non-methadone (e.g., buprenorphine) administration (procedure code H2010) for opioid addiction must be submitted with the following modifiers:

When non-methadone is administered with supervision in a facility the provider must submit claims using the modifier combination of HG and UA to indicate opioid addiction treatment facility doses or claims will be denied

When non-methadone is dispensed without supervision as a take home dose the provider must submit claims using the modifier combination of HG and U1 to indicate opioid addiction take home doses or claims will be denied

MAT provided in an ambulatory (outpatient) setting (procedure code H2010 with modifier HG and procedure code H2010 with modifier HF), is limited to once per date of service, except for unsupervised take home doses (U1 modifier), by any provider. Reimbursement for procedure code H2010 with modifiers HG and U1 is limited to a quantity of 30 per 30 days.

Non-methadone administration (procedure code H2010-HG) with modifier U1 for unsupervised take home doses must be submitted on the same claim and with the same date of service as non-methadone administration (procedure code H2010-HG) with modifier UA for supervised facility doses or the take home doses will be denied.

When non-methadone is administered in a facility for a non-opioid treatment, providers must use procedure code H2010 with the HF modifier to indicate non-opioid treatment in a facility.

Non-methadone administration (procedure code H2010) submitted without a modifier will be denied. Physician services may be reimbursed separately using the appropriate evaluation and management procedure codes.

Injectable administration is considered part of MAT and is not reimbursed separately. Procedure code 96372 will be denied when billed for the same date of service by any provider as procedure code H0020 or H2010.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

8.11Noncovered Services

The following SUD services are not a benefit of Texas Medicaid:

Aftercare

Occupational therapy as part of a residential detoxification or treatment program

Services for which the client fails to meet the treatment eligibility or authorization criteria, or which are not clinically appropriate in the setting requested based on the client’s medical condition

Services for tobacco and caffeine addiction

Detoxification services and MAT for hashish or marijuana addiction

Detoxification with an opioid when the client has had two or more unsuccessful opioid detoxifi­cation episodes (has left the program against medical advice) within a 12-month period (see 42 CFR Section 8)

Detoxification or substance abuse counseling services provided by electronic means such as telemedicine, email, or telephone

8.12Claims Filing

Claims for SUD services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

9 Claims Resources

Refer to the following sections or forms when filing claims:

Resource

Location

Acronym Dictionary

“Appendix D: Acronym Dictionary” (Vol. 1, General Information)

Automated Inquiry System (AIS)

Subsection A.10, “TMHP Telephone and Fax Communication” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

CMS-1500 Paper Claim Filing Instructions

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information)

State, federal, and TMHP contact information

“Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

TMHP Electronic Data Interchange (EDI) information

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information)

10 Contact TMHP

Providers can call the TMHP Contact Center at 1-800-925-9126 from Monday through Friday, 7 a.m. to 7 p.m., Central Time.

11 Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com:

Forms

Ambulatory (Outpatient) Detoxification Authorization Request Form

Ambulatory (Outpatient) Substance Abuse Counseling Extension Request Form

Outpatient Mental Health Services Request Form

Residential Detoxification Authorization Request Form

Residential Substance Use Disorder Treatment Request Form

12 Claim Form Examples

The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at www.tmhp.com:

Claim Form Examples

Blind Children’s Vocational Discovery and Development Program (BCVDDP)

Case Management for Children and Pregnant Women

Licensed Clinical Social Worker (LCSW)

Licensed Marriage and Family Therapist (LMFT)

Licensed Professional Counselor (LPC)

Mental Health Case Management

Psychologist

Psychotherapy with Evaluation and Management (E/M)