Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.21-007 - Extension of Benefits for Acute Crisis Units and Substance Abuse Detoxification and Telemedicine for Specific Services
Current through Register Vol. 49, No. 9, September, 2024
Outpatient Behavioral Health Services Section II
TOC not required
252.111 Individual Behavioral Health Counseling 1-1-22
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90832, U4 90834, U4 90837, U4 90832, U4, U5 - Substance Abuse 90834, U4, U5 - Substance Abuse 90837, U4, U5 - Substance Abuse 90832, UC, UK, U4 - Under Age 4 90834, UC, UK, U4 - Under Age 4 90837, UC, UK, U4 - Under Age 4 |
90832: psychotherapy, 30 min 90834: psychotherapy, 45 min 90837: psychotherapy, 60 min |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Individual Behavioral Health Counseling is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration. Additionally, tobacco cessation counseling is a component of this service. |
- Date of Service - Start and stop times of face-to-face encounter with beneficiary - Place of service - Diagnosis and pertinent interval history - Brief mental status and observations - Rationale and description of the treatment used that must coincide with Mental Health Diagnosis - Beneficiary's response to treatment that includes current progress or regression and prognosis - Any revisions indicated for the diagnosis, or medication concerns - Plan for next individual therapy session, including any homework assignments and/or advanced psychiatric directive or crisis plans - Staff signature/credentials/date of signature |
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NOTES |
UNIT |
BENEFIT LIMITS |
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Services provided must be congruent with the objectives and interventions articulated on the most recent Mental Health Diagnosis. Services must be consistent with established behavioral healthcare standards. Individual Psychotherapy is not permitted with beneficiaries who do not have the cognitive ability to benefit from the service. |
90832: 30 minutes 90834: 45 minutes 90837: 60 minutes |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) encounter between all three (3) codes. YEARLY MAXIMUM OF ENCOUNTERS THAT |
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This service is not for beneficiaries under four (4) years of age except in documented exceptional cases. This service will require a Prior Authorization for beneficiaries under four (4) years of age. |
MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiary: Twelve (12) encounters between all three (3) codes |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults Residents of Long-Term Care Facilities |
A provider may only bill one (1) Individual Behavioral Health Counseling Code per day per beneficiary. A provider cannot bill any other Individual Behavioral Health Counseling Code on the same date of service for the same beneficiary. For Counseling Level Beneficiaries, there are twelve (12) total individual counseling encounters allowed per year regardless of code billed for Individual Behavioral Health Counseling, unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE (POS) |
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- Independently Licensed Clinicians - Master's/Doctoral - Non-independently Licensed Clinicians - Master's/Doctoral - Advanced Practice Nurses - Physicians - Providers of services for beneficiaries under four (4) years of age must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90853, U4 90853, U4, U5 - Substance Abuse |
Group psychotherapy (other than of a multiplefamily group) |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Group Behavioral Health Counseling is a face-to-face treatment provided to a group of beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support their rehabilitation effort, and to minimize relapse. Services pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Date of Service * Start and stop times of actual group encounter that includes identified beneficiary * Place of service * Number of participants * Diagnosis * Focus of group * Brief mental status and observations * Rationale for group counseling must coincide with Mental Health Assessment * Beneficiary's response to the group counseling that includes current progress or regression and prognosis * Any changes indicated for diagnosis, or medication concerns * Plan for next group session, including any homework assignments or crisis plans, or both * Staff signature/credentials/date of signature |
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NOTES |
UNIT |
BENEFIT LIMITS |
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This does NOT include psychosocial groups. Beneficiaries eligible for Group Behavioral Health Counseling must demonstrate the ability to benefit from experiences shared by others, the ability to participate in a group dynamic process while respecting the others' rights to confidentiality and must be able to integrate feedback received from other group members. For groups of beneficiaries eighteen (18) years of age and over, the minimum number that must be served in a specified group is two (2). The maximum that may be served in a specified group is twelve (12). For groups of beneficiaries under eighteen (18) years of age, the minimum number that must be served in a specified group is two (2). The maximum that may be served in a specified group is ten (10). A beneficiary must be four (4) years of age to receive group therapy. Group treatment must be age and developmentally appropriate, (i.e., sixteen (16) year-olds and four (4) year-olds must not be treated in the same group). Providers may bill for services only at times during which beneficiaries participate in group activities. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiary: Twelve (12) encounters |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults |
A provider can only bill one (1) Group Behavioral Health Counseling encounter per day. For Counseling Level Beneficiaries, there are twelve (12) total group behavioral health counseling encounters allowed per year, unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, eighteen (18) years of age and above) |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
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* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians |
02 (Telemedicine), 03 (School), 11 (Office), 49 (Independent Clinic), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substances Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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252.113 Marital/Family Behavioral Health Counseling with Beneficiary Present 1-1-22
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90847, U4 90847, U4, U5 - Substance Abuse 90847, UC, UK, U4 - Dyadic Treatment * |
Family psychotherapy (conjoint psychotherapy) (with patient present) |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Marital/Family Behavioral Health Counseling with Beneficiary Present is a face-to-face treatment provided to one (1) or more family members in the presence of a beneficiary. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems, and needs. Services pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Date of Service * Start and stop times of actual encounter with beneficiary and spouse/family * Place of service * Participants present and relationship to beneficiary * Diagnosis and pertinent interval history * Brief mental status of beneficiary and observations of beneficiary with spouse/family * Rationale, and description of treatment used must coincide with the Mental Health Diagnosis and improve the impact the beneficiary's condition has on the spouse/family or improve marital/family interactions between the beneficiary and the spouse/family, or both |
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*Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children who are from zero through forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment must be prior authorized and is only available for beneficiaries in Tier One (1). Dyadic Infant/Caregiver Psychotherapy is a behaviorally based therapy that involves improving the parent-child relationship by transforming the interaction between the two parties. The primary goal of Dyadic Infant/Parent Psychotherapy is to strengthen the relationship between a child and his or her parent (or caregiver) as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect and improving the child's cognitive, behavioral, and social functioning. This service uses child directed interaction to promote interaction between the parent and the child in a playful manner. Providers must utilize a nationally recognized evidence-based practice. Practices include, but are not limited to, Child-Parent Psychotherapy (CPP) and Parent Child Interaction Therapy (PCIT). **Dyadic treatment by telemedicine must continue to assure adherence to the evidence-based protocol for the treatment being provided, i.e. PCIT would require a video component sufficient for the provider to be able to see both the parent and child, have a communication device (ear phones, ear buds, etc.) to enable the provider to communicate directly with the parent only while providing directives related to the parent/child interaction. |
* Beneficiary and spouse/family's response to treatment that includes current progress or regression and prognosis * Any changes indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * Staff signature/credentials/date of signature * HIPAA compliant Release of Information, completed, signed, and dated |
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NOTES |
UNIT |
BENEFIT LIMITS |
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Natural supports may be included in these sessions if justified in service documentation and if supported in the documentation in the Mental Health Diagnosis. Only one (1) beneficiary per family, per therapy session, may be billed. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level |
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Beneficiaries: Twelve (12) encounters |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults |
A provider can only bill one (1) Marital/Family Behavioral Health Counseling with (or without) Patient encounter per day. There are twelve (12) total Marital/Family Behavioral Health Counseling with Beneficiary Present encounters allowed, per year, unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid. The following codes cannot be billed on the Same Date of Service: 90849 - Multi-Family Behavioral Health Counseling 90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present H2027 -- Psychoeducation |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
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* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90846, U4 90846, U4, U5 - Substance Abuse 90846, U4, U5 - Substance Abuse, Telemedicine |
Family psychotherapy (without the patient present) |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Marital/Family Behavioral Health Counseling without Beneficiary Present is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support, and develop alternative strategies to address familial issues, problems, and needs. Services pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition, or both. Additionally, tobacco cessation counseling is a component of this service. Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural competence. |
* Date of Service * Start and stop times of actual encounter spouse/family * Place of service * Participants present and relationship to beneficiary * Diagnosis and pertinent interval history * Brief observations with spouse/family * Rationale, and description of treatment used must coincide with the Mental Health Diagnosis and improve the impact the beneficiary's condition has on the spouse/family, or improve marital/family interactions between the beneficiary and the spouse/family, or both * Beneficiary and spouse/family's response to treatment that includes current progress or regression and prognosis * Any changes indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * Staff signature/credentials/date of signature * HIPAA compliant Release of Information, completed, signed, and dated |
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NOTES |
UNIT |
BENEFIT LIMITS |
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Natural supports may be included in these sessions, if justified in service documentation, and if supported in Mental Health Diagnosis. Only one (1) beneficiary per family per therapy session may be billed. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiaries: Twelve (12) encounters |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults |
A provider can only bill one (1) Marital/Family Behavioral Health Counseling with (or without) Beneficiary encounter per day. The following codes cannot be billed on the Same Date of Service: 90849 - Multi-Family Behavioral Health Counseling 90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present H2027 -- Psychoeducation |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
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* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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H2027, U4 H2027, UK, U4 - Dyadic Treatment* |
Psychoeducational service; per fifteen (15) minutes |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Psychoeducation provides beneficiaries and their families with pertinent information regarding mental illness, substance abuse, and tobacco cessation, and teaches problemsolving, communication, and coping skills to support recovery. Psychoeducation can be implemented in two (2) formats: multifamily group and/or single-family group. Due to the group format, beneficiaries and their families are also able to benefit from support of peers and mutual aid. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Date of Service * Start and stop times of actual encounter with beneficiary and spouse/family * Place of service * Participants present * Nature of relationship with beneficiary * Rationale for excluding the identified beneficiary * Diagnosis and pertinent interval history * Rationale and objective used must coincide |
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*Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. Dyadic treatment must be prior authorized. Providers must utilize a national recognized evidencebased practice. Practices include, but are not limited to, Nurturing Parents and Incredible Years. |
with Mental Health Diagnosis and improve the impact the beneficiary's condition has on the spouse/family or improve marital/family interactions between the beneficiary and the spouse/family, or both * Spouse/family response to treatment that includes current progress or regression and prognosis * Any changes indicated for the diagnosis, or medication concerns * Plan for next session, including any homework assignments or crisis plans, or both * HIPAA compliant Release of Information forms, completed, signed, and dated * Staff signature/credentials/date of signature |
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NOTES |
UNIT |
BENEFIT LIMITS |
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Information to support the appropriateness of excluding the identified beneficiary must be documented in the service note and medical record. Natural supports may be included in these sessions when the nature of the relationship with the beneficiary and that support's expected role in attaining treatment goals is documented. Only one (1) beneficiary per family per therapy session may be billed. |
Fifteen (15) minutes |
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: Four (4) YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): forty-eight (48) |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults |
A provider can only bill a total of forty-eight (48) units of Psychoeducation The following codes cannot be billed on the Same Date of Service: 90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present 90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present H2027 -- Psychoeducation |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
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* Independently Licensed Clinicians -Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurse |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 |
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* Physician * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians -Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider |
(Rural Health Clinic) |
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252.117 Mental Health Diagnosis 1-1-22
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90791, U4 90791, UC, UK, U4 - Dyadic Treatment * |
Psychiatric diagnostic evaluation (with no medical services) |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Mental Health Diagnosis is a clinical service for the purpose of determining the existence, type, nature, and appropriate treatment of a mental illness, or related disorder, as described in the current allowable DSM. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostics process may include, but is not limited to: a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face or telemedicine component and will serve as the basis for documentation of modality and issues to be addressed (plan of care). Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * Presenting problem(s), history of presenting problem(s) including duration, intensity, and response(s) to prior treatment * Culturally and age-appropriate psychosocial history and assessment * Mental status (Clinical observations and impressions) * Current functioning plus strengths and needs in specified life domains * DSM diagnostic impressions * Treatment recommendations and prognosis for treatment * Goals and objectives to be placed in Plan of Care * Staff signature/credentials/date of signature |
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NOTES |
UNIT |
BENEFIT LIMITS |
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This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes This service can be provided via telemedicine. *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. A Mental Health Diagnosis will be required for all children through forty-seven (47) months of age to receive services. This service includes up to four (4) encounters for children through the age of forty-seven (47) months of age and can be provided without a prior authorization. This service must include an assessment of: * Presenting symptoms and behaviors * Developmental and medical history * Family psychosocial and medical history * Family functioning, cultural and communication patterns, and current environmental conditions and stressors * Clinical interview with the primary caregiver and observation of the caregiver-infant relationship and interactive patterns and * Child's affective, language, cognitive, motor, sensory, selfcare, and social functioning |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults Residents of Long-Term Care |
The following codes cannot be billed on the Same Date of Service: 90792 - Psychiatric Assessment |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
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ALLOWABLE PERFORMING PROVIDER |
PLACE OF SERVICE |
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* Independently Licensed Clinicians * Master's/Doctoral |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 |
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* Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified in specific evidence-based practices to be reimbursed for those services * Independently Licensed Clinicians * Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians * Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider |
(Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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252.118 Interpretation of Diagnosis 1-1-22
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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90887, U4 90887, UC, UK, U4 - Dyadic Treatment |
Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data, to family or other responsible persons (or advising them how to assist patient) |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Interpretation of Diagnosis is a direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures, or accumulated data. Services may include diagnostic activities or advising the beneficiary and their family. Services pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition, or both. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Start and stop times of face-to-face encounter with beneficiary and/or parent(s) or guardian(s) * Date of service * Place of service * Participants present and relationship to beneficiary * Diagnosis * Rationale for and objective used that must coincide with the Mental Health Diagnosis * Participant(s) response and feedback * Recommendation for additional supports including referrals, resources, and information * Staff signature/credentials/date of signature(s) |
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NOTES |
UNIT |
BENEFIT LIMITS |
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For beneficiaries under eighteen (18) years of age, the time may be spent face-to-face with the beneficiary; the beneficiary and the parent(s) or guardian(s); or alone with the parent(s) or guardian(s). For beneficiaries over eighteen (18) years of age, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian, or significant other. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT |
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This service can be provided via telemedicine to beneficiaries eighteen (18) years of age and above. This service can also be provided via telemedicine to beneficiaries seventeen (17) years of age and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record. *Dyadic treatment is available for parent/caregiver and child for dyadic treatment of children from zero through forty-seven (0-47) months of age and parent/caregiver. Interpretation of Diagnosis will be required in order for all children, through forty-seven (47) months of age, to receive services. This service includes up to four (4) encounters for children through fortyseven (47) months of age and can be provided without a prior authorization. The Interpretation of Diagnosis is a direct service that includes an interpretation from a broader perspective, based on the history and information collected through the Mental Health Diagnosis. This interpretation identifies and prioritizes the infant's needs, establishes a diagnosis, and helps to determine the care and services to be provided. |
MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Counseling Level Beneficiary: One (1) |
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APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
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Children, Youth, and Adults |
The following codes cannot be billed on the Same Date of Service: H2027 - Psychoeducation 90792 - Psychiatric Assessment 90849 - Multi-Family Behavioral Health Counseling H0001 - Substance Abuse Assessment This service can be provided via telemedicine to beneficiaries eighteen (18) years of age and above. This service can also be provided via telemedicine to beneficiaries seventeen (17) years of age and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record. |
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ALLOWED MODE(S) OF DELIVERY |
TIER |
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Face-to-face Telemedicine Adults, Youth and Children |
Counseling |
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ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
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* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians * Providers of dyadic services must be trained and certified, in specific evidence-based practices, to be reimbursed for those services * Independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider * Non-independently Licensed Clinicians - Parent/Caregiver and Child (Dyadic treatment of Children from zero through forty-seven (0-47) months of age and Parent/Caregiver) Provider |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
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252.119 Substance Abuse Assessment 1-1-22
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CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
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H0001, U4 |
Alcohol and/or drug assessment |
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SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
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Substance Abuse Assessment is a service that identifies and evaluates the nature and extent of a beneficiary's substance abuse condition using the Addiction Severity Index (ASI) or an assessment instrument approved by DAABHS and DMS. The assessment must screen for and identify any existing co-morbid conditions. The assessment should assign a diagnostic impression to the beneficiary, resulting in a treatment recommendation and referral appropriate to effectively treat the condition(s) identified. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs, as identified by the beneficiary, and provided with cultural competence. |
* Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * Presenting problem(s), history of presenting problem(s) including duration, intensity, and response(s) to prior treatment * Cultural and age-appropriate psychosocial history and assessment * Mental status (Clinical observations and impressions) * Current functioning and strengths in specified life domains * DSM diagnostic impressions * Treatment recommendations and prognosis for treatment * Staff signature/credentials/date of signature |
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|
NOTES |
UNIT |
BENEFIT LIMITS |
|
The assessment process results in the assignment of a diagnostic impression, beneficiary recommendation for treatment regimen appropriate to the condition and situation presented by the beneficiary, initial plan (provisional) of care, and referral to a service appropriate to effectively treat the condition(s) identified. If indicated, the assessment process must refer the beneficiary for a psychiatric consultation. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
|
APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
|
|
Children, Youth, and Adults |
The following codes cannot be billed on the Same Date of Service: 90887 - Interpretation of Diagnosis |
|
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face Telemedicine (Adults, Youth, Children) |
Counseling |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
* Independently Licensed Clinicians - Master's/Doctoral * Non-independently Licensed Clinicians - Master's/Doctoral * Advanced Practice Nurses * Physicians |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
|
252.121 Pharmacologic Management 1-1-22
|
CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
|
|
99212, UB, U4 - Physician 99213, UB, U4 - Physician 99214, UB, U4 - Physician 99212, SA, U4 - APN 99213, SA, U4 - APN |
99212: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: A problem focused history; A problem focused examination; or straightforward medical decision making. |
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|
99214, SA, U4 - APN |
99213: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: An expanded problem focused history; An expanded problem-focused examination; or medical decision making of low complexity. 99214: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: A detailed history, A detailed examination; or medical decision making of moderate complexity. |
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|
SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
|
|
Pharmacologic Management is a service tailored to reduce, stabilize, or eliminate psychiatric symptoms, with the goal of improving functioning, including management and reduction of symptoms. This service includes evaluation of the medication prescription, administration, monitoring, and supervision, as well as informing beneficiaries regarding potential effects and side effects of medication(s), in order to make informed decisions regarding the prescribed medications. Services must be congruent with the age, strengths, and accommodations necessary for disability and cultural framework. Services must be congruent with the age and abilities of the beneficiary, client-centered, and strength-based; with emphasis on needs as identified by the beneficiary and provided with cultural competence. |
* Date of Service * Start and stop times of actual encounter with beneficiary * Place of service (When ninety-nine (99) is used for telemedicine, specific locations of the beneficiary, and the physician must be included) * Diagnosis and pertinent interval history * Brief mental status and observations * Rationale for and treatment used that must coincide with the Psychiatric Assessment * Beneficiary's response to treatment that includes current progress or regression and prognosis * Revisions indicated for the diagnosis, or medication(s) * Plan for follow-up services, including any crisis plans * If provided by physician that is not a psychiatrist, then any off-label uses of medications should include documented consult with the overseeing psychiatrist within twenty-four (24) hours of the prescription being written * Staff signature/credentials/date of signature |
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|
NOTES |
UNIT |
BENEFIT LIMITS |
|
Applies only to medications prescribed to address targeted symptoms as identified in the Psychiatric Assessment. |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): Twelve (12) |
|
APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
|
|
Children, Youth, and Adults | ||
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face Telemedicine (Adults, Youth, and Children) |
Counseling |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
* Advanced Practice Nurse * Physician |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office), 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
|
252.122 Psychiatric Assessment 1-1-22
|
CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
|
|
90792, U4 |
Psychiatric diagnostic evaluation with medical services |
|
|
SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
|
|
Psychiatric Assessment is a face-to-face psychodiagnostics assessment conducted by a licensed physician or Advanced Practice Nurse (APN), preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under eighteen (18) years of age). This service is provided to determine the existence, type, nature, and most appropriate treatment of a behavioral health disorder. This service is not required for beneficiaries to receive Counseling Level Services. |
* Date of Service * Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation * Place of service * Identifying information * Referral reason * The interview should obtain or verify the following: 1. The beneficiary's understanding of the factors leading to the referral 2. The presenting problem (including symptoms and functional impairments) 3. Relevant life circumstances and psychological factors 4. History of problems 5. Treatment history 6. Response to prior treatment interventions 7. Medical history (and examination as indicated) * For beneficiaries under eighteen (18) years of age 1. an interview of a parent (preferably both), the guardian (including the responsible DCFS caseworker), and the primary caretaker (including foster parents) as applicable in order to: a) Clarify the reason for the referral b) Clarify the nature of the current symptoms c) Obtain a detailed medical, family, and developmental history * Culturally and age-appropriate psychosocial history and assessment * Mental status/Clinical observations and impressions * Current functioning and strengths in specified life domains * DSM diagnostic impressions * Treatment recommendations * Staff signature/credentials/date of signature |
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|
NOTES |
UNIT |
BENEFIT LIMITS |
|
This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes (i.e. treatment plans, etc.). |
Encounter |
DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: One (1) YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): One (1) |
|
APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
|
|
Children, Youth, and Adults Telemedicine (Adults, Youth, and Children) |
The following codes cannot be billed on the Same Date of Service: 90791 - Mental Health Diagnosis |
|
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face |
Counseling |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
A. an Arkansas-licensed physician, preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under eighteen (18) years of age) B. an Adult Psychiatric Mental Health Advanced Nurse Practitioner/Family Psychiatric Mental Health Advanced Nurse Practitioner (PMHNP-BC) The PMHNP-BC must meet all of the following requirements: A. Licensed by the Arkansas State Board of Nursing B. Practicing with licensure through the American Nurses Credentialing Center C. Practicing under the supervision of an Arkansas-licensed psychiatrist with whom the PMHNP-BC has a collaborative agreement. The findings of the Psychiatric Assessment conducted by the PMHNP-BC, must be discussed with the supervising psychiatrist within forty-five (45) days of the beneficiary entering care. The collaborative agreement must comply with all Board of Nursing requirements and must spell out, in detail, what the nurse is authorized to do and what age group they may treat D. Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act E. Practicing within a PMHNP-BC's experience and competency level |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office), 12, (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic) |
|
255.001 Crisis Intervention 1-1-22
|
CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
|
|
H2011, HA, U4 |
Crisis intervention service, per fifteen (15) minutes |
|
|
SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
|
|
Crisis Intervention is unscheduled, immediate, short-term treatment activities provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services are designed to stabilize the person in crisis, |
* Date of service * Start and stop time of actual encounter with beneficiary and possible collateral contacts with caregivers or informed persons * Place of service * Specific persons providing pertinent information in relationship to beneficiary |
|
|
prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. (These activities include evaluating a Medicaid-eligible beneficiary to determine if the need for crisis services is present.) Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and their family. |
* Diagnosis and synopsis of events leading up to crisis situation * Brief mental status and observations * Utilization of previously established psychiatric advance directive or crisis plan as pertinent to current situation OR rationale for crisis intervention activities utilized * Beneficiary's response to the intervention that includes current progress or regression and prognosis * Clear resolution of the current crisis and/or plans for further services * Development of a clearly defined crisis plan or revision to existing plan * Staff signature/credentials/date of signature(s) |
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|
NOTES |
UNIT |
BENEFIT LIMITS |
|
A psychiatric or behavioral crisis is defined as an acute situation, in which an individual is experiencing a serious mental illness or emotional disturbance to the point that the beneficiary or others are at risk for imminent harm, or in which to prevent significant deterioration of the beneficiary's functioning. This service can be provided to beneficiaries that have not been previously assessed or have not previously received behavioral health services. The provider of this service MUST complete a Mental Health Diagnosis (90791) within seven (7) days of provision of this service, if provided to a beneficiary who is not currently a client. If the beneficiary cannot be contacted or does not return for a Mental Health Diagnosis appointment, attempts to contact the beneficiary must be placed in the beneficiary's medical record. If the beneficiary needs more time to be stabilized, this must be noted in the beneficiary's medical record and the Division of Medical Services Quality Improvement Organization (QIO) must be notified. |
Fifteen (15) minutes |
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: twelve (12) YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): seventy-two (72) |
|
APPLICABLE POPULATIONS |
SPECIAL BILLING INSTRUCTIONS |
|
|
Children, Youth, and Adults | ||
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face Telemedicine (Adults, Youth, and Children) |
Crisis |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
* Independently Licensed Clinicians - Master's/Doctoral |
02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 15 |
|
|
* Non-independently Licensed Clinicians - Master's/Doctoral (must be employed by Behavioral Health Agency) * Advanced Practice Nurses * Physicians (must be employed by Behavioral Health Agency) |
(Mobile Unit), 23 (Emergency Room), 33 (Custodial Care facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57( Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic), 99 (Other Location) |
|
255.003 Acute Crisis Units 1-1-22
|
CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
|
|
H0018, U4 |
Behavioral Health; short-term residential |
|
|
SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
|
|
Acute Crisis Units provide brief (96 hours or less) crisis treatment services to persons eighteen (18) years of age and over, who are experiencing a psychiatric- or substance abuse-related crisis, or both, and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and stepdown services in a safe environment with psychiatry and substance abuse services onsite at all times, as well as on-call psychiatry available twenty-four (24) hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed. | ||
|
NOTES |
EXAMPLE ACTIVITIES |
|
|
APPLICABLE POPULATIONS |
UNIT |
BENEFIT LIMITS |
|
Adults |
Per Diem |
* Ninety-six (96) hours or less per admission; Extension of Benefits required for additional days |
|
PROGRAM SERVICE CATEGORY |
||
|
Crisis Services |
||
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face |
N/A |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
Acute Crisis Units must be certified by the |
55 (Residential Substance Abuse Treatment |
|
|
Division of Provider Services and Quality Assurance as an Acute Crisis Unit Provider. |
Facility), 56 (Psychiatric Residential Treatment Center |
|
255.004 Substance Abuse Detoxification 1-1-22
|
CPT®/HCPCS PROCEDURE CODE |
PROCEDURE CODE DESCRIPTION |
|
|
H0014, U4 |
Alcohol and/or drug services; detoxification |
|
|
SERVICE DESCRIPTION |
MINIMUM DOCUMENTATION REQUIREMENTS |
|
|
Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term and may be provided in a crisis unit, inpatient, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment. Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment. | ||
|
NOTES |
EXAMPLE ACTIVITIES |
|
|
APPLICABLE POPULATIONS |
UNIT |
BENEFIT LIMITS |
|
Youth and Adults |
N/A |
* Six (6) encounters per SFY; Extension of Benefits required for additional encounters |
|
PROGRAM SERVICE CATEGORY |
||
|
Crisis Services |
||
|
ALLOWED MODE(S) OF DELIVERY |
TIER |
|
|
Face-to-face |
N/A |
|
|
ALLOWABLE PERFORMING PROVIDERS |
PLACE OF SERVICE |
|
|
Substance Abuse Detoxification must be provided in a facility that is certified by the Division of Provider Services and Quality Assurance as a Substance Abuse Detoxification provider. |
55 (Residential Substance Abuse Treatment Facility) |
|
305.000 Telemedicine Billing Guidelines 1-1-22
Telemedicine is defined as the use of electronic information and communication technology to deliver healthcare services including without limitation, the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. Telemedicine includes store-and-forward technology and remote patient monitoring. (See policy section I.)
Arkansas Medicaid shall provide payment for telemedicine healthcare services to licensed or certified healthcare professionals or entities that are authorized to bill Arkansas Medicaid directly for healthcare services. Coverage and reimbursement for healthcare services provided through telemedicine shall be reimbursed on the same basis as healthcare services provided in person.
Payment will include a reasonable facility fee to the originating site (the site at which the patient is located at the time telemedicine healthcare services are provided). In order to receive reimbursement, the originating site must be operated by a healthcare professional or licensed healthcare entity that is authorized to bill Medicaid directly for healthcare services. The distant site is the location of the healthcare provider delivering telemedicine services. Services at the distant site must be provided by an enrolled Arkansas Medicaid Provider who is authorized by Arkansas law to administer healthcare.
Coding Guidelines:
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS
ATTACHMENT 3.1-A
13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
xxix. Crisis Care - De-escalation*
Eligibility for this service is determined by an Independent Assessment and must be prior authorized.
DEFINITION: Crisis Care - De-escalation provides temporary direct care for a beneficiary in the beneficiary's community that is not facility-based. Crisis Care - De-escalation services de-escalate stressful situations and provide a therapeutic outlet. Crisis Care includes behavioral interventions that keep beneficiaries in their current situation and reduces the need for acute hospitalization or other higher levels of care. Crisis Care shall be indicated in the treatment plan.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Crisis Care - De-escalation provider must be certified by the Department of Human Services as a Crisis Care - De-escalation provider.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.
xxx. Acute Crisis Units*
Definition: Acute Crisis Units provide brief 96 hours or less) crisis treatment services to persons over the age of 17 who are experiencing a psychiatry and/or substance abuse-related crisis and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and step-down services in a safe environment with psychiatry and/or substance abuse services on-site at all times as well as on-call psychiatry available 24 hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Acute Crisis Unit must be certified by Department of Human Services as an Acute Crisis Unit.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelors; and Qualified Behavioral Health Provider - Non-Degreed.
An Extension of Benefit for medical necessity is required for admissions exceeding ninety-six (96) hours.
*All medically necessary 1905(a) services, that correct or ameliorate physical and mental illnesses and conditions, are covered for EPSDT eligible beneficiaries, ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.
13. Other diagnostic, screening, preventive and rehabilitative services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services (continued)
3. Outpatient Behavioral Health Services (OBHS)
xxxi. Crisis Intervention*
DEFINITION: Crisis Intervention is an unscheduled, immediate, short-term treatment activity provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and their family. These services, which can include interventions, stabilization activities, evaluation, coping strategies, and other various activities to assist the beneficiary in crisis, are designed to stabilize the person in crisis, prevent further deterioration, and provide immediate indicated treatment in the least restrictive setting. The services provided are expected to reduce or eliminate the risk of harm to the person or others in order to stabilize the beneficiary.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician
xxxii. Substance Abuse Detoxification*
Definition: Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term, may be provided in a crisis unit, residential, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment.
Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Substance Abuse Detoxification Unit must be certified by the Department of Human Services as a Substance Abuse Detoxification provider.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.
Six encounters are allowed per State Fiscal Year (July 1 through June 30). Extension of Benefits for Medically Necessary Encounters beyond the first six (6) is required.
*All medically necessary 1905(a) services, that correct or ameliorate physical and mental illnesses and conditions, are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.
ATTACHMENT 3.1-B
13. Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
3. Outpatient Behavioral Health Services (OBHS)
xxix. Crisis Care - De-escalation*
Eligibility for this service is determined by an Independent Assessment and must be prior authorized.
DEFINITION: Crisis Care - De-escalation provides temporary direct care for a beneficiary in the beneficiary's community that is not facility-based. Crisis Care - De-escalation services de-escalate stressful situations and provide a therapeutic outlet. Crisis Care includes behavioral interventions that keep beneficiaries in their current situation and reduces the need for acute hospitalization or other higher levels of care. Crisis Care shall be indicated in the treatment plan.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Crisis Care - De-escalation provider must be certified by the Department of Human Services as a Crisis Care - De-escalation provider.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.
xxx. Acute Crisis Units*
Definition: Acute Crisis Units provide brief, 96 hours or less, crisis treatment services to persons over the age of 17 who are experiencing a psychiatry- and/or substance abuse-related crisis and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and step-down services in a safe environment with psychiatry and/or substance abuse services on-site at all times as well as on-call psychiatry available 24 hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Acute Crisis Unit must be certified by Department of Human Services as an Acute Crisis Unit.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.
An Extension of Benefit for medical necessity is required for admissions exceeding ninety-six (96) hours.
*All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.
13. Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in this plan.
d. Rehabilitative Services
3. Outpatient Behavioral Health Services (OBHS)
xxxi. Crisis Intervention*
DEFINITION: Crisis Intervention is an unscheduled, immediate, short-term treatment activity provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services, which can include interventions, stabilization activities, evaluation, coping strategies and other various activities to assist the beneficiary in crisis, are designed to stabilize the person in crisis, prevent further deterioration, and provide immediate indicated treatment in the least restrictive setting. The services provided are expected to reduce or eliminate the risk of harm to the person or others, in order to stabilize the beneficiary.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician
xxxii. Substance Abuse Detoxification*
Definition: Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term and may be provided in a crisis unit, residential, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment. Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment.
Substance Abuse Detoxification Unit must be certified by the Department of Human Services as a Substance Abuse Detoxification provider.
This service will not be paid for within an Institution for Mental Disease (IMD).
This service does not include payment for room and board of the beneficiary.
Allowable Performing Provider - Independently Licensed Clinician - Master's/Doctoral; Non-Independently Licensed Clinician - Master's/Doctoral; Advanced Practice Nurse; Physician; Registered Nurse; Qualified Behavioral Health Provider - Bachelor's; and Qualified Behavioral Health Provider - Non-Degreed.
Six (6) encounters are allowed per State Fiscal Year (July 1 through June 30). Extension of Benefits for Medically Necessary Encounters beyond the first six (6) is required.
*All medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions are covered for EPSDT eligible beneficiaries ages birth to twenty-one, in accordance with 1905(r) of the Social Security Act.
