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 1.7.1.2, “Reporting Child Abuse or Neglect” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) and subsection 1.7.1.5, “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 eligible persons 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 eligible persons 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).

Section 1.1, “About the Vendor Drug Program” in the Outpatient Drug Services Handbook (Vol. 2, Provider Handbooks) for information about this program.

1.1​Payment 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 3.7.4.17, “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)

2.1​Overview

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 child 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

2.2​Enrollment

Texas Health and Human Services Commission (HHSC) Blind Children’s Vocational Discovery and Development Program (BCVDDP) is the Medicaid provider of case management for persons who are 22 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 BCVDDP case management activities.

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

2.3​Services, Benefits, Limitations, and Prior Authorization

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

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

​Refer to: Subsection A.8, “Texas Health and Human Services Commission Blind Children’s Vocational Discovery and Development Program (BCVDDP)” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

2.3.1​Prior Authorization

Prior authorization is not required for BCVDDP case management services.

2.4​Documentation 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.

2.5​Claims 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 person 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. HHSC BCVDDP 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 HHS website at www.hhs.texas.gov/.

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/resources/rate-and-code-updates/rate-changes.

​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

3.1​Overview

Case management services are provided to help Medicaid eligible persons gain access to necessary medical, social, educational, and other services. Case managers assess a person’s need for these services and then develop a service plan to address those needs. Case Management for Children and Pregnant Women (CPW) services are outlined in the Texas Administrative Code (TAC).

3.1.1​Eligibility

CPW services are a benefit for children birth through 20 years of age who:

•​Are Medicaid eligible in Texas.

•​Have, or are at risk for, a health condition illness, injury, or disability that results in limitation of function, activities, or social roles in comparison with healthy peers of the same age in the general areas of physical, cognitive, emotional, or social growth and development.

•​Are in need of Case Management for Children and Pregnant Women services.

•​Choose such services.

CPW services are a benefit for pregnant women of any age who:

•​Are Medicaid eligible in Texas.

•​Are pregnant and have a medical and/or psychosocial condition(s) that places them and their fetus(es) at a greater than average risk for complications, either during pregnancy, delivery, or following birth.

•​Are in need of Case Management for Children and Pregnant Women services.

•​Choose such services.

Clients that are Medicaid-eligible, but not yet enrolled may have Medicaid coverage assigned retroactively.

Verbal or written consent must be obtained from the client, parent, or legal guardian prior to the initiation of any CPW services. If the client receiving CPW services is a minor, all CPW services and visits must be completed with a parent or legal guardian present.

3.1.2​Referral Process

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

•​Visit www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women to obtain a referral form.

•​Call THSteps toll free at 877-847-8377 from 8 a.m. to 6 p.m., Central Time, Monday through Friday.

•​Contact a Case Management for Children and Pregnant Women provider directly at www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women. A case management provider will contact the client to offer a choice of providers and obtain information necessary to determine eligibility for case management services.

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

3.2​Enrollment

Providers must be at least 18 years of age, enrolled in Medicaid, and approved by the Health and Human Services Commission (HHSC) to provide CPW services.

A provider shall not be approved as a provider of CPW services unless they meet one of the following qualifications:

•​APRN who holds a license under Texas Occupations Code Chapter 301; or

•​Registered nurse (RN) who holds a license under Texas Occupations Code Chapter 301 and has a baccalaureate degree in nursing, or

•​RN who holds a license under Texas Occupations Code Chapter 301 and has an associate degree in nursing with:

•​At least 2 years cumulative paid full-time work experience; or two years of supervised, full-time educational internship/practicum experience in the past ten years with children, up to age 21, and/or pregnant women; or

•​Social worker who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 505, appropriate for the individual’s practice, including the practice of independent social work in the State of Texas; or

•​Community health worker as defined by Section 48.001, Health and Safety Code, who is certified by the Department of State Health Services; or

•​Doula who is certified in alignment with nationally recognized standards, and as determined by HHSC, must have:

•​Five years of experience within the last seven years as a doula; and

•​Attendance in three births in the last seven years; and

•​Three written professional letters of recommendation.

•​Doula who is certified in alignment with nationally recognized standards, and as determined by HHSC, who is without five years of experience as a doula must have:

•​Attendance in three births; and

•​Three written professional letters of recommendation; and

•​Training in core competencies is required and must include:

•​Childbirth education

•​Lactation support (or proof of being a certified lactation counselor (CLC) or International Board-Certified Lactation Counselor (IBCLC)

•​Nonmedical comfort measures, prenatal support, and labor support techniques

•​Chronic and acute health conditions during the perinatal period

•​Cultural competency training

A Federally Qualified Health Center (FQHC) that has obtained HHSC approval may be eligible to provide CPW case management services. FQHCs must:

•​Use the FQHC provider type, specialty code, and taxonomy code to deliver CPW services.

•​Use their own individual National Provider Identifier (NPI) to deliver services.

Enrollment for Case Management for Children and Pregnant Women providers is a four-step process. Providers must complete all of the following:

•​A pre-planning process with HHSC.

•​The HHSC standardized case management training provided by HHSC.

•​The Health Insurance Portability and Accountability Act (HIPAA) training.

​Note:CPW Authorization to Disclose Protected Health Information forms in English or Spanish located on the HHSC CPW website must be completed as necessary to help the client access services.

•​Providers must receive an approval letter from HHSC to enroll as a state Medicaid provider of CPW services.

Providers may be a group, an individual, or perform services under guidance of a FQHC.

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

3.3​Services, Benefits, Limitations, and Prior Authorization

Case Management for Children and Pregnant Women services are limited to one contact per day per person. Additional provider contacts on the same day are denied as part of another service rendered on the same day. Prior authorization is not required for case management services.

Procedure code G9012, with required modifiers, may be reimbursed for Case Management for Children and Pregnant Women (CPW) services. Modifiers are used to identify which service component is provided.

Comprehensive visits are limited to one service per client, per provider in 12 consecutive months from the intake date.

CPW services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio- only) technologies. Services delivered using audio-only technologies must be billed using the 93 modifier.

Comprehensive visits completed in-person must be billed with procedure code G9012 and modifiers U2 and U5.

Comprehensive visits completed using synchronous audiovisual technology must be billed with procedure code G9012 and modifiers U2, U5 and 95.

Comprehensive visits may not be completed or billed using synchronous telephone (audio-only) technology.

Follow-up visits completed in-person must be billed with procedure code G9012 and modifiers U5 and TS.

Follow-up visits completed using synchronous audiovisual technology must be billed with procedure code G9012 and modifiers U5, TS and 95.

Follow-up visits completed using synchronous telephone (audio-only) technology must be billed with procedure code G9012 and modifiers TS and 93.

Procedure code G9012 is limited to once per day, any service, any provider.

FQHC’s will bill for services using procedure code G9012 with the corresponding modifiers.

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 person 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.

​Note:For CPW services delivered through a managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, reimbursement, and specific claim processing procedures.

Providers and their case managers must operate in accordance with the laws, rules, regulations, and standards of care relating to the practice of their respective license(s) or certifications.

Providers must provide services according to policies and procedures as published.

Providers must cease providing services and notify HHSC if the professional license or certification of a provider is suspended or revoked.

Providers must assure that case managers attend required trainings provided by HHSC.

Providers must provide services convenient to clients, either in their home, an office setting, or other place of the client’s preference.

Providers must have knowledge of, and coordinate services with, providers of health and health-related services, non-covered services, and other active community resources.

Providers must develop and maintain a quality management system for the provision of services.

Providers may be disenrolled by HHSC for failure to comply with provisions of the TMHP Provider Agreement or any applicable law, rule, or policy of the program.

Providers must submit claims for rendered case management services. If no claims are submitted for 24 months, the provider will be disenrolled.

Providers may be disenrolled for not providing services for 12 months or longer.

During a Declaration of State Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Providers are to disseminate accurate information regarding case management services to health, education, and human service professionals, community organizations, and potential clients to generate referrals. Some examples may include:

•​Participate in community outreach events such as health fairs.

•​Network with community agencies that serve children and pregnant women.

•​Participate in community coalition meetings.

•​Distribute brochures to medical/mental health professionals, dental providers, community resources, and schools.

•​Conduct presentations.

•​Develop community resource documents to include:

•​Local resources supporting nonmedical needs.

•​Providers accepting Medicaid clients.

•​Any other information about resources available specific to the provider’s population served.

Providers must ensure that outreach activities do not impede a client’s freedom to choose a provider.

Providers must refer and adhere to CPW outreach guidance available on the HHSC CPW website when producing outreach materials.

Providers must comply with the requirements outlined in TAC Title 1, Part 15, Chapter 371, Rule §371.1669, concerning Self-Dealing.

3.3.1​Initial Intake

CPW providers must complete an initial intake with the client, parent, or legal guardian to determine the client’s eligibility. The following information must be obtained during the initial intake and must be documented on the CPW Intake and Referral Form located on the HHSC CPW website:

•​The health condition(s), health risk, or high-risk condition of the client who would receive case management services

•​The health-related non-medical conditions of the eligible client who would receive case management services.

•​How the health condition, health risk, or high-risk condition impacts the client’s level of functioning

•​Detailed information about the client’s current need(s) related to the health condition, health risk, high-risk, or non-medical condition

•​How the CPW provider will assist the client with their current need(s)

If the client to receive services is a minor, then the initial intake must be completed with the person’s parent or legal guardian present.

The CPW initial intake service is not billable for reimbursement but is a required function of case management services. Providers who are unable to accept a referral, based on approved limitations, must re-direct the referral to the Texas Health Steps Hotline (1-877-THSteps or 1-877-847-8377). The approved limitations are:

•​The client resides outside the provider service area.

•​The provider is not contracted with the managed care organization (MCO) that is responsible for delivering services to the client.

•​The provider has disenrolled as a CPW provider from TMHP.

•​The provider cannot serve the individual’s needs.

Referrals received for clients in STAR Kids must receive an intake to determine if there are needs for coordinating school services. All other services are to be provided by the client’s MCO.

If the CPW initial intake indicates the client is eligible for services and a need for CPW services is identified, then the provider must complete a comprehensive visit within 30 business days of the intake date in which eligibility was determined.

If the CPW initial intake indicates the client is eligible for services and a need for CPW services is identified, but the client is not yet enrolled in Medicaid, then the case manager must complete a comprehensive visit within thirty (30) business days after the client’s enrollment period is established.

3.3.2​Comprehensive Visits

The comprehensive visit (procedure code G9012 with the appropriate modifier combination) is a reimbursable service.

The comprehensive visit must include the completion of all the following:

•​Family Needs Assessment

•​Service Plan

•​Service Plan Consent

The comprehensive visit must be completed within 30 business days of the intake date on which eligibility was determined or retroactive eligibility is established. If the client receiving CPW services is a minor, the comprehensive visit must be completed with the person’s parent or legal guardian present. The comprehensive visit may be completed in-person or through the use of synchronous audiovisual technology. Comprehensive visits using synchronous audiovisual technology should only be provided if agreed to by the client, parent or legal guardian.

The FNA is completed to determine the need for any medical, educational, social, or other services required to address the client’s short- and long-term health and the overall well-being of the client. The FNA must include the following documentation using the FNA form located on the HHSC CPW website:

•​Completing a personal and family medical, mental health, and medication history.

•​Identifying the client’s needs, including any non medical health-related needs.

•​Assessing and providing a referral for personal and family issues that impact the client’s health condition, health risk, high-risk condition, or non-medical needs and completing related documentation.

•​Gathering information from other sources, such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the client.

The Service Plan (SP) is part of the comprehensive visit and must be completed and documented during the comprehensive visit using the Service Plan form on the HHSC CPW website. The Service Plan Consent is completed to authorize the provider to share information as necessary for referrals and for services to be provided. The Service Plan Consent form is located on the HHSC CPW website.

The SP is completed to determine a planned course of action. The service plan must include:

•​Activities and goals that are developed in consultation with the client, parent, or legal guardian, involve the participation of the client, and address the medical, social, educational, and other services that are needed by the client receiving CPW services.

•​Identify a course of action to respond to the assessed needs of the client, including identifying the individual responsible for contacting the appropriate service providers, and designating the time frame within which the client should access services.

The Service Plan may also include:

•​Referral and related activities to help the client obtain needed services, including activities that help link the client with third parties such as medical, social, and educational providers.

•​Case management may include collateral 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.

•​Participating in meetings.

•​Providing resource information.

•​Problem solving and advocating for the client.

The service plan must be translated or interpreted in the client’s preferred language.

The Service Plan and Service Plan Consent forms must have verbal or written consent by the client, parent, or legal guardian and kept in the client’s record, to be made available upon request.

3.3.3​Follow-up Visits

Follow-up visits (procedure code G9012 with the appropriate modifier combination) are reimbursable services, and may only be completed after the comprehensive visit has been completed. The follow-up visit and comprehensive visit cannot occur on the same day.

Follow-up visits by a case manager are necessary to ensure the Service Plan is implemented and adequately addresses the client’s needs.

Follow-up visits shall be conducted as frequently as necessary. At least one annual follow-up is required for clients who are eligible for case management lasting longer than 12 consecutive months. For reimbursement, follow-up visits must be documented and must include the following:

•​The current service plan to include the client’s needs and status

•​Services are being furnished in accordance with the client’s service plan

•​How services are addressing the client’s needs as outlined in the Service Plan

•​Service is maintained and modified when the client’s needs or status changes

If the client receiving CPW services is a minor, the follow-up visit must be completed with the client’s parent or legal guardian present.

​Note:Follow-up visit forms are available on the HHSC CPW website at: www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women.

Follow-up visits are completed to ensure the service plan is implemented and adequately addresses the person’s needs. A follow-up visit must include but is not limited to:

•​Ensuring services are being furnished in accordance with the person’s service plan.

•​Ensuring services in the service plan are adequate.

•​Ensuring the service plan is modified when the person’s need(s) changes.

Activities during the follow-up visit must be documented on the Follow-up form found on the HHSC CPW website and must include:

•​Reviewing all outstanding needs documented on the Service Plan.

•​Problem solving with the client, parent, or legal guardian.

•​Problem solving when the client, parent, or legal guardian has not followed through with identified Service Plan action steps.

•​Assessing for new needs.

•​Determining the next course of action to address outstanding needs.

A follow-up visit may be completed in-person or through the use of synchronous audiovisual technology, or synchronous telephone (audio-only) technology. Follow-up visits completed using synchronous audiovisual technology or synchronous telephone (audio-only) technology should only be provided if agreed to by the client, parent, or legal guardian.

CPW activities that occur between follow-up visits are necessary components of case management for children and pregnant women services, but are not billable. These activities may include:

•​Phone calls to the client, parent, or legal guardian between billable follow-up visits.

•​Gathering information from other sources, such as family members, medical providers, social workers, and educators on behalf of the client, parent, or legal guardian.

Follow-up visits by the case manager for clients who are pregnant with a high-risk condition or non-medical needs shall occur as needed during the 12-month postpartum period. When all needs related to the health condition, health risk, high-risk pregnancy, or non-medical needs have been addressed, then CPW services must no longer be provided.

The client status is to be documented on the Case Closure Form available on the HHSC CPW website, to identify the outcome of the case when the following apply:

•​All eligible needs have been addressed or resolved.

•​The client is no longer eligible for case management due to an improvement in their health condition, health risk, or high-risk condition.

•​The child reaches 21 years of age and does not meet other eligibility requirements for CPW services.

•​The client is no longer eligible for Medicaid and does not anticipate obtaining Medicaid in the near future.

•​The client no longer chooses to receive services.

•​The client is denied additional visits because documentation does not support continued eligibility.

•​The client is lost to follow-up when provider has made three attempts on different dates to contact client, parent, or legal guardian.

•​The client relocates or transfers to a new provider.

•​The provider is unable to render services due to the disruptive, unruly, threatening, or uncooperative behavior of the client, parent, or legal guardian.

​Note:Providers may choose to close a case if the client, parent, or legal guardian is disruptive, unruly, threatening, or uncooperative to the extent the client, parent, or legal guardian seriously impairs the provider’s ability to render services or if the client, parent, or legal guardian’s behavior jeopardizes the client’s own safety, or the providers. The provider should also contact the appropriate authority when necessary.

3.3.4​Case Transfers

Prior authorization is not required for CPW case management services.

Case transfers must be documented on the Case Transfer form available on the HHSC CPW website. The Case Transfer form is completed if the client continues to meet eligibility criteria, but the case needs to be transferred. Transfers may occur for the following reasons:

•​The client requests a transfer.

•​The client relocates.

•​The provider’s service area changes.

•​The provider disenrolls as an active CPW provider.

•​There is a need to change to another case manager.

The provider must assist a client with a transfer to case management services to another area of Texas.

A client must give approval to a provider to transfer the case management record to the new provider.

Providers must appropriately link clients of a family member that is a migrant worker to resources in the geographic areas in which they live and to which they migrate. This case transfer process is to be documented on the Migrant Information Form available on the HHSC CPW website. Providers are to:

•​Determine the family members that migrate.

•​Identify the source(s) of payment for medical care if family migrates outside of Texas.

•​Determine the location and timeframe for each migrating location.

•​Document each new location address, contact persons, medical providers, and school attendance, if needed.

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

3.4.1​Assistance with Program Concerns

Providers who have questions, concerns, or problems with program rule, policy, or procedure may contact HHSC program staff at askcm@hhs.texas.gov.

3.5​Documentation Requirements

All CPW services require documentation to describe and support the medical necessity of the service rendered.

Providers must maintain accurate demographic information on their provider record with TMHP. Changing significant provider information must be updated on the Provider Enrollment Management System (PEMS) within seven calendar days of the change including:

•​Group Name or Doing Business As (DBA)

•​Location Address

•​Telephone Number

•​Fax Number

•​Email Address

Documentation in the client’s record must include that verbal or written consent was obtained from the client, parent, or legal guardian prior to the initiation of any CPW services.

CPW forms including the Family Needs Assessment, Service Plan, Follow-Up form, follow-up documentation, and progress notes must be completed and maintained in the client’s record. The documentation maintained must meet the requirements as outlined in this handbook. CPW documentation forms are available on the HHSC CPW website at hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women.

Signatures, or documentation confirming verbal consent was received, must be included on all forms and documents that require signatures. All forms and documents completed in relation to CPW services must be maintained in the client’s record.

All contacts with or on behalf of the client, parent, or legal guardian must be documented and maintained in the client’s record. Documentation of activities, not otherwise documented on CPW required forms, must be recorded on the Progress Notes form available on the HHSC CPW website. Progress notes may include the following information:

•​Phone calls to the client, parent, or legal guardian between billable follow-up visits

•​Gathering information from other sources, such as family members, medical providers, social workers, and educators on behalf of the client, parent, or legal guardian

Documentation in the client’s record must include the reason(s) a CPW service was not provided or completed. This can be documented on the Referral and Intake form during the initial eligibility determination or on the Case Closure form available on the HHSC CPW website.

Records are subject to review by HHSC or its designee.

3.6​Claims Filing and Reimbursement

3.6.1​Claims Information

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

The comprehensive visit must not be billed until the FNA and SP are completed, and the SP Consent form is signed or verbal consent is given by the client, parent, or legal guardian. The CPW initial intake service is not billable.

Activities that occur between follow-up visits are necessary components of case management but are not billable. These activities must be documented on a progress note. These activities may include:

•​Phone calls to the client, parent, or legal guardian between billable follow-up visits.

•​Collateral contacts on behalf of a client, parent, or legal guardian.

Claims for a client who receives retroactive eligibility must be submitted within 95 days of the date that the client’s eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service (DOS).

Claims for a client who has been approved for Medicaid coverage but has not been assigned a Medicaid client number, the 95-day filing deadline does not begin until the date the eligibility is added to the TMHP eligibility file.

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/resources/rate-and-code-updates/rate-changes.

​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.

3.6.1.1​Exclusions

CPW services are not billable for clients who have already received another case management service on the same day from any billing provider.

CPW services are not billable when a client is in an inpatient at a hospital or other treatment facility.

CPW services are not billable when the exact services are duplicated within the client’s managed care organization.

3.6.2​Managed Care Clients

Case Management for Children and Pregnant Women services are carved in to Medicaid managed care and must be billed to 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 person 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, family, or group), psychological, neurobehavioral, or neuropsychological testing, pharmacological management, and electroconvulsive therapy (ECT).

Outpatient mental health services are benefits when provided in the office, home, skilled nursing or intermediate care facility (SNF/ICF), outpatient hospital, extended care facility (ECF), or in other locations.

Outpatient mental health services are benefits of Texas Medicaid when provided to persons who are experiencing a mental health condition that is causing distress, dysfunction, 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).

4.1​Provider 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” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about procedures for enrolling as a Medicaid provider.

4.1.1​Physicians

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.

4.1.2​Physician 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.

4.1.3​* Advanced Practice Registered Nurses (APRNs)

[Revised] 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 (BON). 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.

4.1.4​Licensed 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.

4.1.5​Licensed 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 must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LMFT is enrolling as part of a Medicare-enrolled group, then the LMFT must also be 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.

4.1.6​Licensed 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 must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LPC is enrolling as part of a Medicare-enrolled group, then the LPC must also be 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.

4.1.7​Psychologists

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.

4.1.8​Licensed 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 required 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.

Psychological services provided by an LPA must be billed under the supervising psychologist’s National Provider Identifier (NPI) or the NPI of the legal entity employing the supervising psychologist.

4.1.9​Provisionally 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 required 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 required 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 NPI.

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

4.1.10​Post-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 required supervision of a licensed psychologist.

Psychology interns are not independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s NPI.

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

4.1.11​Pre-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 required supervision of a licensed psychologist.

Psychology interns are not independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s NPI.

4.2​Services, Benefits, Limitations

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

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

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

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

Procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 are limited to the following diagnosis codes:

4.2.1​Telemedicine and Telehealth Services

Providers must defer to the needs of the person receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the person’s choice and not provider convenience.

Providers must provide outpatient mental health services to Medicaid eligible persons in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. In addition, providers must deliver, to include delivery by telemedicine or telehealth, outpatient mental health services in full accordance with all applicable licensure and certification requirements.

During a Declaration of State of Disaster, the Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

4.2.1.1​Synchronous Audiovisual Technology

The following outpatient mental health services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Outpatient mental health services provided by synchronous audiovisual technology must be billed using modifier 95.

•​Psychiatric diagnostic evaluation services with and without medical services (procedure codes 90791 and 90792)

•​Psychotherapy (individual, family, or group) services (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853)

•​Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only

•​Neurobehavioral services (procedure codes 96116 and 96121).

•​Neuropsychological and psychological testing services (procedure codes 96130, 96131, 96132, 96133, 96136 and 96137) if the following conditions are met:

•​The psychometric test must be available in an online format, except for tests that are administered and responded to orally;

•​The provider, or test administrator, must observe the person, in real-time, for the duration of the test; and

•​The provider delivers the psychometric test in accordance with their licensing board and professional guidelines.

4.2.1.2​Synchronous Telephone (audio-only) Technology

The following outpatient mental health services may be provided by synchronous telephone (audio-only) technology to persons with whom the billing provider has an existing clinical relationship and, if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as, the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of outpatient mental health services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology.

Outpatient mental health services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

•​Psychiatric diagnostic evaluation services with and without medical services (procedure codes 90791 and 90792)

•​Psychotherapy (individual, family, or group) services (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853)

•​Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) from the same billing provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual outpatient mental health service by the same billing provider prior to the initial synchronous telephone (audio-only) service may not be waived.

​Note:“Same billing provider” refers to providers that are within the same entity or organization, as identified by the entity’s or organization’s NPI number or numbers, if the entity or organization has multiple locations (e.g., a clinic/group practice, federally qualified health clinic or rural health clinic, and can include providers within the same community mental health center).

​Note:The required in-person or synchronous audiovisual-delivered outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) may be delivered by another authorized professional or paraprofessional of the same billing provider as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

The billing provider is required to conduct at least one in-person or synchronous audiovisual outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological] or ECT) every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the billing provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12-month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

•​The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area

•​An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition(s)

​Note:The required in-person or synchronous audiovisual-delivered outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) may be delivered by another authorized professional or paraprofessional of the same billing provider (see note above for the definition of same billing provider) as the professional, or paraprofessional, who delivers the service by synchronous telephone (audio-only) technology.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telemedicine and telehealth requirements to include informed consent and privacy and security requirements.

4.2.2​Psychotherapy Services

Individual psychotherapy is defined as therapy that focuses on a single person.

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

Family psychotherapy is defined as 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 code 90832, 90834, or 90837) and family psychotherapy (procedure code 90846 or 90847) on the same day for the same person. 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 person. Documentation that supports the provision of distinct or independent services must be maintained in the person’s medical record and made available to Texas Medicaid upon request.

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

​Refer to: Subsection 9.2.59.6, “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 person, per day.

Psychotherapy is limited to 30 individual, group, or family psychotherapy visits per person, 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 information for the person receiving services

•​Provider name and NPI

•​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 Department of Family and Protective Services (DFPS)-directed services

Providers with an established relationship with a person receiving services must request prior authorization when they determine the person is approaching 30 psychotherapy visits for the calendar year. If the person changes providers during the year and the new provider is unable to obtain complete information on the person’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 services must include:

•​Start and end time of session

•​Modality or modalities utilized

•​Frequency of psychotherapy sessions

•​Clinical notes for each visit must include diagnosis, symptoms, functional status, focused mental status examination (if indicated), treatment plan (goals and objectives addressed), prognosis, and progress, and the name, signature, and credentials of the individual performing the services.

4.2.2.1​Family Psychotherapy

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

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

Family psychotherapy for Medicaid eligible persons 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 may 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

4.2.2.2​Treatment for Alzheimer’s Disease and Dementia

Psychotherapy for persons with Alzheimer’s disease or dementia is a benefit of Texas Medicaid for persons with very mild or mild cognitive decline.

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

4.2.3​Delegated Services

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

Services performed by a LPA or PLP will be reimbursed at 70 percent of the psychologist rate. Services performed by the psychology intern or post-doctoral fellow will be reimbursed at 50 percent of the psychologist rate.

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

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 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.

4.2.4​Pharmacological Management Services

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

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

Pharmacological management is limited to one service per day, per person, 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 person’s condition, along with modifier UD to designate the visit as primarily focused on pharmacological management.

Supporting documentation for pharmacological management services must include:

•​Complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

•​Current list of medications

•​Current psychiatric symptoms and problems, including presenting mental status

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

•​Any medication modifications made during a 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

4.2.5​Electroconvulsive 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, neurobehavioral, 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 or group or family psychotherapy on the same day, by the same provider will be denied as part of another procedure.

4.2.6​Psychiatric Diagnostic Evaluation Services

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 physicians, psychologists, APRNs, PAs, LCSWs, LPCs, LMFTs, PLPs, psychology interns, and post-doctoral fellows.

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

Psychiatric diagnostic evaluations with and without medical services (procedure codes 90791 and 90792) are limited to once per person, 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 DFPS directive

•​If a major change of status occurs

Supporting documentation for psychiatric diagnostic evaluation services must include:

•​Reason for referral or presenting problem

•​Prior diagnoses and any prior treatment

•​Other pertinent medical, social, and family history

•​Clinical observations and results of mental status examination

•​Complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

•​Recommendations, including expected long- and short-term goals

4.2.7​Psychological, Neurobehavioral, and Neuropsychological Testing Services

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

Psychological testing (procedure codes 96130, 96131, 96136, and 96137) and neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137) are limited to eight hours per person, 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 information for the person receiving services

•​Provider name and NPI

•​Current DSM diagnoses

•​Indication of court-ordered or DFPS-directed services

•​Type of testing requested (psychological, neurobehavioral, or neuropsychological) including specific procedure codes

•​Rationale for requested testing, to include the current symptoms of the person receiving services

•​Previous history and testing results

Psychological, neurobehavioral, and neuropsychological testing will not be reimbursed to an APRN or a PA. The most appropriate office 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 codes 96130, 96131, 96136, and 96137) or neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137) 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.

Neurobehavioral testing (procedures codes 96116 and 96121) will not be paid for the same date of service to the same provider as psychological testing (procedure codes 96130, 96131, 96136 and 96137) or neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137). All documentation must be maintained by the provider in the person’s medical record.

The reimbursement for procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 includes the face-to-face testing and the scoring and interpretation of the results. The number of units of testing on the claim for procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 must be in accordance with the allowable activities outlined in each code description.

​Note:Add-on procedure codes indicated with asterisk must be billed with the appropriate primary procedure code.

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

4.2.7.1​Testing 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 person has experienced significant change in mental status requiring specialized testing, or to evaluate a person’s competency to return to a community-based setting. Persons 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 services must include:

•​Reason for referral or presenting problem

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

•​The scoring of the test

•​Location where the testing is performed

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

•​Test interpretations, including narrative descriptions of the test findings

•​Length of time spent by each provider, as applicable, in 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, including 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 person’s condition requires testing over two days and the person does not return, or the person’s condition precludes completion of the testing.

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 person’s medical record at the facility.

4.3​Prior Authorization

Prior authorization requests must 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 must adhere to prior authorization requirements.

4.3.1​Services Requiring Prior Authorization

Prior Authorization is required for the following services:

•​Psychiatric diagnostic evaluation (procedure code 90791 or 90792) after the one evaluation per person, 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

•​Neurobehavioral testing (procedure codes 96116 and 96121) after the 4 hour per day limitations have been met

•​Psychological testing (procedure code 96130, 96131, 96136, or 96137) or neuropsychological testing (procedure code 96132, 96133, 96136, or 96137) after the 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:

•​Diagnosis(es)

•​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

4.3.2​Prior Authorization Not Required

Prior authorization is not required for the following services:

•​One psychiatric diagnostic evaluation (procedure codes 90791 and 90792) per person, 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 person per calendar year

•​4 hours of psychotherapy services per person per day

•​4 hours of neuropsychological testing (procedure codes 96116 and 96121) per person per day

•​8 hours of psychological, neurobehavioral, or neuropsychological testing (procedure codes 96130, 96131, 96132, 96133, 96136, or 96137) per person, per calendar year

•​ECT (procedure code 90870)

4.4​Documentation 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 person’s medical record supports the medical necessity of the services provided. Documentation requirements for a telemedicine or telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided by telemedicine or telehealth.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telemedicine and telehealth documentation requirements including requirements for informed consent.

4.5​Twelve 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 persons 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.

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.

4.6​Court-Ordered Services

The court-ordered services listed below for persons who are age 20 years of age and younger or 65 years of age and older are not subject to utilization management reviews, including prior authorization, concurrent reviews, or retrospective reviews that have the effect of denying, reducing, or controverting the court-ordered service. In these situations, the court order is considered the determination of medical necessity.

When billed with modifier H9, court-ordered services are not subject to the 12-hour system limitation per provider, per day.

Federal law prohibits the use of federal Medicaid funding for medical care provided to persons who are considered incarcerated. A person is considered incarcerated when a criminal justice facility has custody of the person. Examples include:

•​A person who is currently residing in a criminal justice facility and receiving treatment through a program at the criminal justice facility.

•​A person who is committed under Title 1 Texas Code of Criminal Procedure §46(B), which addresses persons ages 18 and older who have been ordered to receive competency restoration.

•​A person who is committed under Title 3 Texas Family Code §§55.01-55.45. These sections refer to persons committed to inpatient psychiatric care because they are deemed unfit to proceed.

The following court-ordered services are required to be provided to Medicaid eligible persons who are not considered incarcerated:

•​Emergency detention ordered by a judge or magistrate under Title 7 Texas Health and Safety Code §§573. 011-573.026.

•​Mental health services ordered under Title 7 Texas Health and Safety Code §§574.01-574.110. Mental health services may include:

•​A mental health examination.

•​Inpatient or outpatient treatment.

•​Detention under protective custody and temporary mental health services.