Virginia Medicaid Outpatient Psychiatric Covered Services

1
Virginia Medicaid Outpatient Psychiatric Covered
Services
Department of Medical Assistance Services

• February-March 2004

www.dmas.virginia.gov
2
Training Objectives

• Identify Medicaid covered Outpatient Psychiatric
  services for adults and children
• Recognize Provider requirements for participation
  in the Virginia Medicaid program
• Apply appropriate service limitations when
  providing service
• Demonstrate knowledge of Medicaid documentation
  requirements
• Apply accurate billing information to CMS1500
  forms

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Provider Qualifications for Psychiatric Services

• PSYCHIATRIST licensed physician who has
  completed at least three years of postgraduate
  residency training in psychiatry
• LICENSED CLINICAL PSYCHOLOGIST licensed by
  Department of Health Professions, Board of
  Psychology

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Provider Qualifications for
Psychiatric Services (contd)

• LICENSED CLINICAL SOCIAL WORKER (LCSW) licensed
  by Department of Health Professions, Board of
  Social Work
• LICENSED PROFESSIONAL COUNSELOR (LPC)licensed by
  the Department of Health Professions, Board of
  Professional Counselors, Marriage and Family
  Therapists, and Substance Abuse Professionals

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Provider Qualifications for
Psychiatric Services (contd)

• PSYCHIATRIC CLINICAL NURSE SPECIALIST -
  PSYCHIATRIC (CNS) licensed by the Board of
  Nursing and certified by the American Nurses
  Credentialing Center
• An individual who has completed his or her
  graduate degree and is working towards licensure,
  under direct supervision

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Supervision of Unlicensed Personnel

• SUPERVISOR
• Appropriately licensed under state law
• Supervision meets requirements of individual
  profession
• Approves and signs Plan of Care
• Reviews Patients medical history
• Countersigns Plan of Care updates

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Supervision of Unlicensed Personnel
(contd)

• Reviews each progress note
• Countersigns each progress note on date of
  service indicating note was reviewed
• Meet regularly (every six sessions)
• Discuss Plan of Care
• Review record
• Note Patients progress
• Document supervisory meetings

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Participation Requirements

• Adhere to conditions outlined in the provider
  agreements
• Notify DMAS of any change in original information
  submitted
• Provider must be participating in the Medicaid
  Program at the time the service is performed

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Participation Requirements

• Ensure freedom of choice to recipients in seeking
  medical care from any institution, pharmacy, or
  practitioner qualified to perform the required
  service(s) and participating in the Medicaid
  Program at the time the service was performed
• Ensure the recipient's freedom to reject medical
  care and treatment

10
Participation Requirements

• Accept as payment in full the amount established
  by DMAS to be the reasonable cost or maximum
  allowable cost
• A provider may not bill a recipient for a covered
  service regardless of whether or not the provider
  received payment from the state
• Should not attempt to collect from the recipient
  or family member any amount that exceeds the
  Medicaid allowance.

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Participation Requirements

• Be in full compliance with the requirements of
  the Rehabilitation Act of 1973, as amended, (29
  U.S.C. 794) which states that no otherwise
  qualified individual with a disability shall be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving federal
  financial assistance. The Act requires reasonable
  accommodations for certain persons with
  disabilities.

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Participation Requirements

• Provides services and supplies to clients in the
  same quality and mode of delivery as provided to
  the general public
• Maintain records for a period of not less than 5
  years (incl. Remits)
• Use Medicaid designated billing forms

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Participation Requirements

• Reimburse the patient or any other party for any
  monies contributed toward the patient's care from
  the date of eligibility. The only exception is
  when a patient is spending down excess resources
  to meet eligibility requirements.
• Accept assignment of Medicare benefits for
  eligible Medicaid recipients

14
Participation Requirements

• Administrative and financial management capacity
  to meet federal and state requirements
• Ability to maintain business and professional
  documentation
• Furnish to authorized state and federal personnel
  access to records and facilities in the form and
  manner requested

15
Participation Requirements

• Be fully compliant with state and federal HIPAA
  confidentiality, use and disclosure requirements

16
Utilization of Insurance Benefits

• Insurance Information- Medicaid is payer of last
  resort. Participating providers are to bill all
  other insurance carriers prior to submitting
  claims to Medicaid
• Workers' Compensation - No Medicaid program
  payments shall be made for a patient covered by
  workers' compensation

17
Utilization of Insurance Benefits

• Title XVIII (Medicare) - Virginia Medicaid will
  pay the amount of any deductible or coinsurance
  up to the Medicaid limits for covered health care
  benefits under Title XVIII of the Social Security
  Act (42 U.S.C. 1395 through 1395ggg) for all
  eligible persons covered by Medicare and Medicaid

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Utilization of Insurance Benefits

• Other Health Insurance - When a client has other
  health insurance (such as CHAMPUS, Blue
  Cross-Blue Shield, or Medicare), Medicaid
  requires that these benefits be used first.
  Supplementation shall be made by the Medicaid
  Program when necessary, but the combined total
  payment from all insurance shall not exceed the
  amount payable under Medicaid had there been no
  other insurance

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Termination of Provider Participation

• A provider may terminate with Medicaid at any
  time with written 30 day notice
• Provider must submit written notification of
  voluntary termination to the Director of DMAS and
  First Health Provider Enrollment Unit thirty days
  prior to the effective date

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Termination of Provider Participation

• Code of Virginia mandates that any such
  (Medicaid) agreement or contract shall
  terminate upon conviction of the provider of a
  felony
• Within 30 days, the provider must notify DMAS of
  the conviction and relinquish the agreement

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Termination of Provider Participation

• DMAS requests renewal of the Participation
  Agreement prior to its expiration date
• DMAS may terminate a provider upon 30 day written
  notification
• Termination from DMAS shall be treated as an
  adverse action, and the provider shall be
  entitled to a reconsideration and/or hearing

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Reconsideration of Adverse Actions

• Process has 3 phases-
• Written response and reconsideration to
  preliminary findings (30 days to submit
  information)
• The informal conference (15 days notice to
  request informal conference)
• The formal evidentiary hearing

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Repayment of Identified Overpayments

• Section 32.1-325.1 of the Code of Virginia,
  mandates that DMAS collect identified
  overpayments
• Repayment must be made on demand unless a
  repayment schedule is agreed upon by DMAS
• When a lump sum cash payment is not made,
  interest will be added on the declining balance
  at the statutory rate

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Outpatient Psychiatric Services Whats Covered ?
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Outpatient psychiatric services are to be
provided in a

• practitioners office
• mental health clinic

Outpatient psychiatric services shall be

• medically prescribed treatment
• documented in an active plan
• designed and signed and dated by a Licensed
  Mental Health Provider (LMHP).

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Recipient Participation

• Recipient must
• require treatment in order to sustain behavioral
  or emotional gains or to restore cognitive
  functional levels, which have been impaired
• be at risk for developing or requires treatment
  for maladaptive coping strategies
• present a reduction in individual adaptive and
  coping mechanism or demonstrates extreme increase
  in personal distress
• and

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Recipient Participation (contd)

• Exhibit -
• deficits in peer relations or in dealing with
  authority
• hyperactivity
• poor impulse control
• clinical depression or
• demonstrates other dysfunctional symptoms having
  an adverse impact on attention and concentration,
  the ability to learn, or the ability to
  participate in employment, educational, or social
  activities.

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Service LimitsNo more than a grand total of
three of any in this list in a seven-day period

• Individual psychotherapy
• Once per day (medical evaluation management is
  included in the psychotherapy code and should NOT
  be billed separately)

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Service Limits (contd)

• Group psychotherapy
• Once per day
• 10 (max) per group
• No sensory stimulation, recreational activities,
  art classes, excursions, eating together counted
• Family psychotherapy
• Once per day

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Service Limits (contd)

• EXCLUSIONS
• Multiple-family group psychotherapy
• Hypnotherapy
• Environmental intervention
• Interpretation of examinations, procedures data
• Preparations of reports

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Psychological and Neuropsychological Testing

• Medical records must document the medical
  necessity
• One testing per six-month period
• Up to four hours of units per testing
• No testing for
• Educational diagnosis
• School admission
• Evaluation of an individual with mental
  retardation before nursing home admission
• Any placement testing

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Non-Covered Psychiatric Services

• Broken appointments
• Remedial education
• Day care
• Rehabilitative alcoholism and drug abuse therapy
• Occupational therapy

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Non-Covered Psychiatric Services
(contd)

• Teaching grooming skills, monitoring activities
  of daily living, bibliotherapy, reminiscence
  therapy, or social interaction
• Telephone consultations
• Mail order prescriptions
• Substance abuse services

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Preauthorization

• During the first year client has utilized
  Virginia Medicaid outpatient psychiatric
  benefits
• Treatment is limited to 5 sessions without
  preauthorization --REGARDLESS OF PROVIDER
• Extensions of up to a total of 47 sessions,
  possible when preauthorized (during first year of
  treatment)
• These initial 5 sessions must be used within one
  year of the first date of service (anniversary
  date) and cannot be carried over into subsequent
  years
• Effective July 1,
  2003

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Preauthorization (contd)

• AFTER FIRST YEAR OF TREATMENT
• 21 years of age older
• Up to 26 preauthorized sessions possible each
  year
• Younger than 21 years of age
• Preauthorized sessions possible in each year when
  medically necessary

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Preauthorization (contd)

• THESE SESSION RESTRICTIONS DO NOT APPLY TO
  THE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION
  (CPT Code 90801) or CPT Code 90862

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Preauthorization (contd)

• Call
• MEDICALL 1-800-772-9996
• (Automated Voice Response System)
• or
• HELPLINE 1-800-552-8627

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Preauthorization Process

• Provider may fax
• DMAS-412, Request for Extension of Psychiatric
  Services
• and
• DMAS-351, Preauthorization Request Fax Sheet
• Fax Numbers [phone]
• [phone]

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Preauthorization Process (contd)

• DMAS-361
• Used for changes and deletions
• Signed dated by qualified professional
• Include additional information
• Include tracking number to be changed
• CPT codes affected
• Total number of units needed
• Dates requested
• Explanation of why change is needed
• New/Updated 412 needed if crossing an anniversary
  date, therapy change, or more sessions requested

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Preauthorization Process (contd)

• DMAS-361
• Deletions must include tracking number
• All units and dates for tracking number are
  deleted
• If any of the units/dates have changed, submit a
  change
• DMAS-361 information can be requested by
  telephone
• TELEPHONE NUMBER FOR PENDS
• QUESTIONS ABOUT REQUESTS
• ALREADY SUBMITTED
• [phone]

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DOCUMENTATIONPLAN OF CARE

• Related to diagnosis
• Indicates need for psychiatric treatment
• Client specific objectives/goals of psychotherapy
  (related to symptoms)
• Treatment modalities why chosen

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PLAN OF CARE (contd)

• Estimated length of treatment
• Frequency of sessions
• Family/caregiver participation
• Reviewed every 90 days/every 6th session,
  whichever time frame is shorter

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Progress Notes

• Written at time service is rendered
• Describe how activities of session relate to
  goals
• Length of session
• Level of clients participation
• Treatment modality

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Progress Notes (contd)

• Type of session (group, individual)
• Progress/lack toward goals
• Plan for next session
• Signed and dated by therapist rendering service
  (if unlicensed, also by supervisor)

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Questions ?
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Thank youwww.dmas.virginia.gov