Current through all regulations passed and filed through September 16, 2024
(A) For the purpose
of medicaid reimbursement, therapeutic behavioral (day treatment), group
service-hourly and per diem, is defined as an intensive, structured,
goal-oriented, distinct and identifiable group treatment service that addresses
the individualized mental health needs of the client. The therapeutic
behavioral group service-hourly and per diem is clinically indicated by
assessment. The environment at this level of treatment is highly structured,
and has an appropriate staff-to-client ratio to guarantee sufficient
therapeutic services and professional monitoring, control, and protection. The
purpose and intent of therapeutic behavioral group service-hourly and per diem
is to stabilize, increase or sustain the highest level of functioning.
(1) Therapeutic behavioral group
service-hourly and per diem must be a group treatment service that includes but
is not limited to the following:
(a) Skills
development of interpersonal and social competency, problem solving, conflict
resolution, and emotions/behavior management,
(b) Developing of positive coping
mechanisms,
(c) Managing mental
health and behavioral symptoms to enhance independent living, and
(d) Psychoeducational services including
instruction and training of persons served in order to increase their knowledge
and understanding of their psychiatric diagnosis(es), prognosis(es), treatment,
and rehabilitation in order to enhance their acceptance, increase their
cooperation and collaboration with treatment and rehabilitation, and favorably
affect their outcomes.
(B) Service requirements.
(1) When the service is provided for less
than 2.5 hours per day, the therapeutic behavioral group service hourly billing
code must be used.
(2) When the
service is provided for 2.5 or more hours per day, the therapeutic behavioral
group service per diem must be used and the service must:
(a) Be delivered at a nationally-accredited
program and must be provided by a licensed practitioner, or an unlicensed
mental health practitioner as described in paragraph (A)(2) of rule
5160-27-08 of the Administrative
Code.
(b) The staff to client ratio
cannot exceed 1:12.
(C) Limitations.
(1) Reimbursement for therapeutic behavioral
group service-hourly and per diem will not be made while the patient is
enrolled in assertive community treatment (ACT), or a
substance use disorder (SUD) residential treatment facility.
(2) For adults, reimbursement for the
following medically necessary behavioral health group services will be limited
to no more than four fifteen-minute units, or one hour per day on the same day
as the therapeutic behavioral group service (hourly, or per diem)
except when prior authorized.
(a)
Group psychotherapy
for mental health or substance use disorder
diagnoses.
(b)
Group therapeutic behavioral services as defined in rule
5160-27-08 of the Administrative
Code.
(c) SUD group
counseling.
(d) Group community
psychiatric supportive treatment.
(3) A therapeutic behavioral group service
per diem and therapeutic behavioral group service hourly reimbursement will not
be reimbursed when delivered
on the same day
by the same billing
provider for the same individual.
(4) A medicaid
recipient can receive one therapeutic behavioral group service per diem service
per day per provider.
Reimbursement of therapeutic
behavioral group service per diem and therapeutic behavioral service hourly by
more than one billing provider to the same individual on the same day is
allowable with prior authorization.
(5)
Other behavioral
health individual services may be reimbursed on the same day as therapeutic
behavioral group service-hourly or therapeutic behavioral group service per
diem.
(D) Providers
must adhere to documentation requirements set forth in rules
5160-1-27 and
5160-8-05 of the Administrative
Code.
