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BEHAVIORAL
HEALTH PROVIDERS MEDICAID PROVIDER
VISITS SUMMER 2017
Brenda Stout
Medicaid Behavioral Health
Program Manager
TOPICS
Behavioral Health Cost Study
Next Steps
Documentation Standards
Key Definitions
Prior Authorization (a.k.a. Cap
Limits)
Provider Enrollment
Provider Contact Information
Retroactive enrollment
Applied Behavioral Analysis
Fee Schedule
Provider Manual
Questions
Contact Information
BEHAVIORAL HEALTH MEDICAID
COST STUDY
Overview
MEDICAID COST STUDY
Community Mental Health and Substance Abuse Treatment Centers
11 surveys received
Providers submitting surveys represent approximately 34% of all CMHC/SATCs but
60% of total CMHC/SATC payments
Independent/Group Practitioners
17 surveys received, 12 are “potentially usable” surveys
Providers submitting surveys represent approximately 4% of all independent/group
practitioners and 8% of total independent/group practitioner’s payments
PROVIDERS SUBMITTING A SURVEY BY COUNTY
78 percent of Wyoming
counties have a provider
that submitted a survey,
representing 83 percent
of Wyoming’s population
Both CPT and HCPCS are used for some services
HCPCS-based payment rates are not associated with professional level
Payment and units differ for the same therapy services based on use of HCPCS or CPT codes
Multiple HCPCS define the same service
Billed and allowed charges are the same for a large proportion of SFY 2016 line items
A large proportion of recipients received more than 20 days of service in SFY 2016
Unit billing for group therapy was more than expected in SFY 2016
1
2
3
4
5
6
7
OBSERVATIONS REGARDING CURRENT
MEDICAID BH RATE STRUCTURE
PROPOSED CHANGES The billing/payment issues identified in the previous slides create
challenges in the development of accurate budget impacts at the State,
service and provider level. The following proposed changes are aimed at
standardizing billing and payment methodologies used
PR
OP
OS
ED
CH
AN
GE
Implement billing changes to simplify and streamline payment
• Reduce HCPCS code duplication
• Adjust provider taxonomies to recognize differences in provider licensure to distinguish between licensed and provisionally licensed professionals, and between Master’s level professionals and below Master’s level professionals
• Use state-specific modifiers to reflect provision of individual and family services in an agency-based versus community-based setting
RA
TIO
NA
LE
• Standardizes billing
• Reduces administrative burden on
state and providers
• Allows for more efficiency and
clear analysis of utilization and
expenditures by service, provider
and diagnosis code
PROPOSED CHANGES, CONT’D P
RO
PO
SE
D C
HA
NG
ES
Pay for assessment and therapy services using the Wyoming RBRVS methodology only (based on CPT code)
• Currently providers can choose between billing based on the HCPCS-based fee schedule or CPT-based RBRVS fee schedule.
RA
TIO
NA
LE
• Allows use of only one rate/payment
methodology for each service and is
consistent with Wyoming Medicaid’s
payment approach used for physicians
and other practitioners
• Reflects differences in resources needed
to provide different services
• Simplifies billing requirements
• Facilitates rate updates through
conversion factor
Adopt Medicare’s payment percentages
for professional level for assessment and
therapy services paid via RBRVS 100% -- Psychiatrists and psychologists
85% -- APRNs
75% -- LCSWs (apply to all other
professionals)
• Varies payment by level of education of
professional providing the service
• Provides consistency with Medicare
• Responds to provider concerns
BEHAVIORAL HEALTH MEDICAID
COST STUDY
Next Steps
ANTICIPATED CHANGES OVER THE NEXT TWO YEARS
Phase I – through Oct 1, 2017 July 1st – Implement limitations on group therapy and new modifiers for family
therapy and collateral contacts
Aug 1st – Implement consolidated behavioral health HCPCS procedure codes
Sept 1st – Implement BH documentation standards, WDH conducts provider visits
and webinar trainings
Oct 1st – Potentially implement BH prior authorization process to support “soft
cap” limit
Phase II – Oct 1, 2017 through 2018 Post Oct 1, 2017
Claims data reflects new billing requirements and prior authorization
process
Post Oct 1, 2018
• Analysis of new claims data
• Further identification of changes to the BH rate structure
Post Jan 1, 2019: Implementation
and monitoring of rate changes
(timing TBD)
10/1
2017
10/1
2018
12/1
2018
1/1
2019 2018 2019 2017 7/1
2017
PROPOSED HCPCS CODE CONSOLIDATION AND NEW MODIFIERS
Service Description Current HCPCS Consolidated HCPCS
Individual/family therapy Agency-based:
• H2019 – MH
• T007 – SA
Community-based
• H2021 – MH
• H0047 – SA
Individual Therapy:
H2019, with modifier TN if performed in a community-based
setting
Family Therapy:
H0004
Day treatment/psychosocial
rehab
H2017 – MH
T1012 – SA
H2017
Comprehensive Medication
Services
H0034 – MH
H2010 – SA
H2010
Group therapy H2019+HQ – MH
H0005 – SA
H2019+HQ
Individual rehabilitation H2014 – MH
H2015 – SA
H2014
Certified peer specialist H2014+HH – MH
H2015+HH – SA
H0038
Case management T1017 – MH
H0006 – SA
T1017, Adults, w/modifier HQ for group
G9012, Children (under 21), w/modifier HQ for group
Note: Providers must use new modifier UK when services
provided are on the behalf of the client to someone other
than the client (referred to as a Collateral Contact).
GROUP THERAPY LIMITATIONS
Three sessions per
day
2.5 hours (10 units)
per session
Maximum 15 clients per therapist
PRIOR AUTHORIZATION PROCESS
WDH is considering
implementation of an electronic
prior authorization system to
address soft cap on BH limits
Services exceeding 20 visits will
need to demonstrate medical
necessity to receive Medicaid
payment
Projected implementation date
will be October 1st, 2017
“Soft Cap” 20 Visit Limit on BH
• Applies to clients 21 years of
age or older
• Therapist must complete a
Behavioral Health Cap Limit
Waiver Request form to request
additional visits
• Additional services may be
available for clients over the age
of 21 served by the
Developmental Disabilities
Comprehensive or Supports
waiver
DOCUMENTATION STANDARDS
Requirements
BEHAVIORAL HEALTH DOCUMENTATION STANDARDS
1. Mental health assessment, diagnosis,
symptoms and identifying the clinical
needs of the client
2. Goals and objectives that address the
concerns of the client
3. Progress towards the identified goals and
objectives and notes
4. Treatment plan reviews and
assessment updates
The
Golden
Thread
WYOMING MEDICAID DOCUMENTATION
Implementation of documentation standards September 1st, 2017
Objectives
Incorporate the Golden Thread documentation standards
Educate providers on the importance of maintaining high quality records related to behavioral health services
Train Medicaid Behavioral Health Providers through webinars, provider visits, manuals, etc.
Many states in the nation use a standard practice for documenting behavioral health services. Washington, Ohio and Colorado use similar documentation rules called the Golden Thread, to assist providers with coding, billing and quality of care for the clients. With documentation rules, a provider will be able to explain services rendered, show medical necessity and maintain quality records for their clients.
DOCUMENTATION REQUIREMENTS
Wyoming Medicaid Rules, Chapter 3, Section 7 (b) states: "A provider
must have completed all required documentation, including required
signatures, before or at the time the provider submits a claim to the
Division. Documentation prepared or completed after the submission
will be deemed to be insufficient to substantiate the claim and Medicaid
funds shall be withheld or recovered."
Federal Regulations (42 CFR 431.107 (a), (b), (c)), Wyoming Medicaid
Rules (Chapter 3, Section 7 (c)) and the Medicaid Provider Participation
Agreement requires providers to furnish, upon request, medical records
involving services provided to Wyoming Medicaid clients.
THINGS TO REMEMBER WHEN DOCUMENTING
SERVICES PROVIDED TO MEDICAID CLIENTS: Always use ink (blue ink is preferred). DO NOT USE PENCIL!
NEVER use White-Out
DO NOT scribble through errors
Mark with a line and initial (i.e., 3:30 p.m. a.m. BKS)
Limit the use of abbreviations
Include the name of client and client Medicaid ID
Location of services
Date of service (include month, day, and year)
Name of service provided (use relevant, professional descriptions)
Keep dates and times in chronological order
Write down when timed services begin and when timed services end consistently using either a.m., p.m., or military time
Write down when timed services begin and when timed services end for each calendar day, even when services are provided over a period of longer than a calendar day
Signature of person performing service
If initials are used, a full signature must be included on each page of documentation
Detailed description of services provided
Document each service on separate forms or schedules
CHANGES TO DOCUMENTATION FOR BH SERVICES
Documentation of the services must contain the following:
Name of the client.
Identify the covered services provided and the procedure code billed to Medicaid.
Identify the date, length of time (start and end times in standard or military format), and location of the service.
Identify all persons involved.
Be legible and contain documentation that accurately describes the services rendered to the client and progress towards identified goals.
Full signature, including licensure or certification of the treating provider involved.
Providers shall not sign for a service prior to the service being completed.
No overlapping behavioral health services.
NOTE: When providing behavioral health services to a Medicaid client, the documentation must contain accurate dates and times the services were rendered (3.11 Record Keeping, Retention and Access, 13.9 Documentation Requirements for All Behavioral Health Providers). Behavioral health services cannot overlap date and time for a client. For example, a client being seen for group therapy on February 28th from 11:00 to 12:00 cannot also be seen for targeted case management on February 28th from 11:00 to 12:00. These are overlapping services and cannot be billed to Medicaid. The importance of proper documentation of services is important to differentiate the times of services being rendered, as you cannot bill times on a CMS 1500.
MEDICAID DEFINITIONS
REHABILITATIVE VS HABILITATIVE SERVICES
Wyoming Medicaid covers medically necessary therapy services, including mental health and substance abuse (behavioral health) treatment and physical, occupational, and speech therapy services via the federal authority guidelines granted by the Centers for Medicare and Medicaid Services (CMS) and specified in the Code of Federal Regulation's (CFR) rehabilitative services option section.
"Medical necessity" or "Medically necessary " means a determination that a health service is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected to relieve pain or to improve and preserve health and be essential to life. The service must be:
(A) Consistent with the diagnosis and treatment of the client's condition;
(B) In accordance with the standards of good medical practice among the provider's peer group;
(C) Required to meet the medical needs of the client and undertaken for reasons other than the convenience of the client and the provider; and,
(D) Performed in the most cost effective and appropriate setting required by the client's condition.
REHABILITATIVE SERVICES
Rehabilitative/Rehabilitation Services: Health care services that help you
keep, get back, or improve skills and functioning for daily living that have
been lost or impaired because you were sick, hurt, or disabled.
Services may include physical and occupational therapy, speech-language
pathology, and psychiatric rehabilitation services in a variety of inpatient
and/or outpatient settings.
HABILITATIVE SERVICES
Habilitative/Habilitation Services: Health care services that help you
keep, learn, or improve skills and functioning for daily living.
Examples include therapy for a child who isn't walking or talking at the expected age.
Services may include physical and occupational therapy, speech-language
pathology, and other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
DISTINGUISHING BETWEEN HABILITATIVE
AND REHABILITATIVE SERVICES The key difference between the two definitions is whether you had the skill
or function.
Rehabilitative Services =If the person did have it and lost it due to a disease or
accident then it would be a rehabilitative service.
Habilitative Services = If the person never had it then it is a habilitative service.
Because Wyoming Medicaid is restricted to the reimbursement of services
that are exclusively rehabilitative and restorative in nature, the Medicaid
Developmental Disability Waiver Program (operating as the Comprehensive
and Supports Waiver in Wyoming) also includes coverage for habilitative
therapy services (physical, speech and occupational) beneficial to clients with a
developmental disability, recognizing that most often the services needed by
these clients are habilitative in nature, and do not meet the requirements of
the rehabilitative services covered by traditional Medicaid.
COLLATERAL CONTACT
Collateral contact is defined as an individual involved in the client’s care.
This individual may be a family member, guardian, healthcare
professional, or person who is a knowledgeable source of information
about the client’s situation and services to support or corroborate
information provided by the client. The individual contributes a direct
and exclusive benefit for the covered client.
Wyoming Medicaid Rules, Chapter 13, Mental Health Services, Section 3
(d).
PROVIDER ENROLLMENT
MEDICAID ENROLLMENT REQUIREMENTS
All Ordering, Referring, Prescribing (ORP), Attending and other Treating
Providers must be enrolled with Wyoming Medicaid.
Effective July 1st, 2016
Per ACA
Any claim submitted without the required ORP or attending physician information,
or submitted with information for a provider who is not enrolled with Medicaid, will
deny and the provider will not receive reimbursement for services.
Supervision of a Behavioral Health Provider
All providers must be enrolled with Wyoming Medicaid.
PROVIDER CONTACT INFORMATION
As enrolled providers, all providers are required to keep up to date
contact information on file with Wyoming Medicaid, including the
following:
Physical Address
Mailing Address for payment information
Mailing Address for correspondence
Phone number
Email address for notifications
Effective September 1st, 2016
PROVIDER CONTACT INFORMATION
Updates may be made by mail, fax, via the web portal Update Demographics (pay-to providers only), or the web portal Ask Medicaid option.
Wyoming Medicaid
Attn: Enrollment
P.O. Box 667
Cheyenne, WY 82003-0667
Phone: 1-800-251-1268
Fax: 307-772-8405
PROVIDER ENROLLMENT
Retroactive enrollments will not be allowed
Per the Affordable Care Act, Section 6401(a) and the Medicaid Provider Enrollment Compendium (MPEC)
Providers will be responsible for keeping their Medicaid enrollment current
Reenrollments will need to begin early enough that they are completed before there is a gap in active enrollment status
Policy is tentatively schedule to begin July 1, 2017
Emergency Retroactive Enrollment Criteria
The provider is out of state
The services are furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state practice location
The furnishing/treating provider is enrolled in an approved status in Medicare or in another state’s Medicaid plan on the date of service
The claim represents either a single instance of care furnished over 180 day period, or multiple instances of care furnished to a single participant, over a 180 day period
APPLIED BEHAVIOR ANALYSIS
TREATMENT
Overview
APPLIED BEHAVIOR ANALYSIS TREATMENT
The Centers for Medicare & Medicaid Services (CMS) is requesting that
states provide services to eligible individuals under the age of 21 years
with autism spectrum disorder (ASD). States should review their
current services for children with ASD and plan an approach to provide
medically necessary services to this population.
CMS Bulletin 7/7/2014
Wyoming Medicaid had 488 clients in State Fiscal Year (SFY) 2015 under
the age of 21 years with an Autism Spectrum Disorder or a pervasive
developmental disorder diagnosis (Wyoming Department of Health).
ABA SERVICES
Applied Behavior Analysis (ABA) treatments are allowable to children between the ages of 0-21 years of age with a diagnosis of Autism Spectrum Disorder.
Applied Behavior Analysis are individualized treatments based in behavioral sciences that focus on increasing positive behaviors and decreasing negative or interfering behaviors to improve a variety of well-defined skills.
ABA is a highly structured program that includes incidental teaching, intentional environmental modifications, and reinforcement techniques to produce socially significant improvement in human behavior.
ABA strategies include reinforcement, shaping, chaining of behaviors and other behavioral strategies to build specific targeted functional skills that are important for everyday life.
APPLIED BEHAVIOR ANALYSIS PROVIDERS Name Abbreviation and Requirements
http://bacb.com/credentials/
Board Certified
Behavior Analysts -
Doctoral
BCBA-D
Be actively certified as a BCBA in Good Standing
Have earned a degree from a doctoral program accredited by the Association for Behavior Analysis International
Or
A certificant whose doctoral training was primarily behavior-analytic in nature, but was not obtained from an ABAI-
accredited doctoral program, may qualify for the designation by demonstrating that his or her doctoral degree met the
following criteria:
(a.)The degree was conferred by an acceptable accredited institution; AND
(b.) The applicant conducted a behavior-analytic dissertation, including at least 1 experiment; AND
(c.) The applicant passed at least 2 behavior analytic courses as part of the doctoral program of study; AND
(d.) The applicant met all BCBA coursework requirements prior to receiving the doctoral degree.
Board Certified
Behavior Analysts
BCBA
Option 1 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate
coursework in behavior analysis, and a defined period of supervised practical experience to apply for the BCBA
examination.
Option 2 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate
coursework in behavior analysis that includes research and teaching, and supervised practical experience to apply for
BCBA examination.
Option 3 requires an acceptable doctoral degree that was conferred at least 10 years ago and at least 10 years post-
doctoral practical experience to apply for the BCBA examination.
APPLIED BEHAVIOR ANALYSIS PROVIDERS Name Abbreviation and Requirements
http://bacb.com/credentials/
Board Certified
Assistant Behavior
Analyst
BCaBA
1. Degree
Applicant must possess a minimum of a bachelor’s degree from an acceptable accredited institution. The bachelor’s degree
may be in any discipline.
2. Coursework
Course work must come from an acceptable institution and cover the required content outlined in the BACB’s Fourth
Edition Task List and Course Content Allocation documents.
3. Experience
Applicants must complete experience that fully complies with all of the current Experience Standards.
4. Examination
Applicants must take and pass the BCaBA examination.
Registered Behavior
Technician
RBT
1. Age and Education
RBT applicants must be at least 18 years of age and have demonstrated completion of high school or equivalent/higher.
2. Training Requirement
The 40-hour RBT training is not provided by the BACB but, rather, is developed and conducted by BACB certificants.
3. The RBT Competency Assessment
The RBT Competency Assessment is the basis for the initial and annual assessment requirements for the RBT credential.
4. Criminal Background Registry Check
To the extent permitted by law, a criminal background check and abuse registry check shall be conducted on each RBT
applicant no more than 45 days prior to submitting an application.
5. RBT Examination
All candidates who complete an RBT application on or after December 14, 2015 will need to take and pass an examination
before credential is awarded.
SERVICE CPT CODE
DESCRIPTION CPT® CODE BILLING
FREQUENCY
SERVICES PERFORMED
BY
Initial assessment (development of
initial treatment plan)
Behavior Identification assessment, by the physician or other
qualified health care professional, face-to-face with patient and
caregiver(s), includes administration of standardized and non-
standardized tests, detailed behavioral history, patient
observation and caregiver interview, interpretation of test
results, discussion of findings and recommendations with the
primary guardian(s)/caregiver(s), and preparation of report.
0359T (untimed
code)
Once per
authorization
period
Authorized ABA
supervisor
Observational behavioral follow-up
assessment for supervised field work
of assistant behavior analysts and
behavior technicians
Observational behavioral follow-up assessment includes physician
or other qualified health care professional direction with
interpretation and report, administered by one technician; first
30 minutes of technician time, face-to-face with the patient.
each additional 30 minutes of technician time, face-to-face with
the patient (List separately in addition to code for primary
service)
0360T (initial 30
minutes per day)
and 0361T (each
additional 30
minutes per day)
As applicable
Authorized ABA
supervisor or delegated
assistant behavior analyst
One-on-one ABA interventions
delivered per ABA treatment plan
protocol (direct hands-on ABA
services)
Adaptive behavior treatment by protocol, administered by
technician, face-to-face with one patient; first 30 minutes of
technician time.
each additional 30 minutes of technician time (List separately in
addition to code for primary procedure)
0364T (initial 30
minutes per day)
and 0365T (each
additional 30
minutes per day)
As applicable
Assistant behavior analyst
or behavior technician
under the tiered delivery
model, or by the
authorized ABA
supervisor under the sole
delivery model
One-on-one ABA intervention to
teach/implement a new or modified
technique from the treatment plan
Adaptive behavior treatment with protocol modification
administered by physician or other qualified health care
professional with one patient; first 30 minutes of patient face-to-
face time
each additional 30 minutes of patient face-to-face time (List
separately in addition to code for primary procedure)
0368T (initial 30
minutes per day)
and 0369T (each
additional 30
minutes per day)
As applicable
Authorized ABA
supervisor
Quarterly meetings between the
ABA supervisor, parents/caregivers
and assistant behavior
analysts/behavior technicians to
discuss treatment modifications
Quarterly
Transition or discharge
reassessments and treatment plan
updates
As applicable
Parent/caregiver(s) training
Family adaptive behavior treatment guidance, administered by
physician or other qualified health care professional (without the
patient present)
0370T
As applicable
Authorized ABA
supervisor or delegated
assistant behavior analyst
PROVIDER INFORMATION
Fee Schedule, Provider Manual, etc.
SPECIFIC CODES FOR CMHC/SATC
Only Community Mental Health Centers and Substance Abuse
Treatment Centers are allowed to bill the following services:
T1017 – Targeted Case Management
H2014/H2015 – Individual Rehabilitative Service
H2017/T1012 – Psychosocial Rehabilitation Services
Per Wyoming Medicaid Rules, Chapter 13 – Mental Health Services,
Section 6 (b)(i-xi)
Per State Plan Amendment, 3.1A 13D
CMS 1500 Provider Manual
CONTINUITY OF CARE DOCUMENT –
CCD VIEWER
Problems
Diagnosis
Family History
Immunizations
Vital Signs
Social History
Test Results
Medications
Procedures
Alerts
Allergies/Adverse Reactions
And more…
The CCD viewer allows authorized users to search for and retrieve a Patient Summary Continuity of Care Document (CCD) for current Medicaid clients. The CCD document is used to supplement the patient’s clinical health record.
The CCD is a HITSP standard patient summary document that contains all of the following information from the THR Gateway:
CCD VIEWER
To request THR CCD Viewer access, please send an e-mail containing: • Clinic Name • Address • Phone Number • Provider Names • Provider Email Addresses • Primary Contact To Andrea Bailey at: [email protected] Visit the website at: http://wyomingthr.wyo.gov/ccd-viewer
FEE SCHEDULE
http://wyequalitycare.acs-inc.com/
Select Provider
Left Side of the Website, Select Fee Schedule
End User Agreement for Providers
Edit and Reimbursement Information
Coverage Indicator
Maximum Units of Service
Taxonomies Allowed
Taxonomy Percentages
Rate
PROCEDURE CODE SEARCH
PROVIDER MANUALS
CMS 1500 Provider Manual
Updated Quarterly
Behavioral Health Section
Documentation Requirements
Treatment Plan Requirements
Allowed Codes
Supervision
Community Mental Health & Substance Use Treatment Services Manual
Discontinued
PROVIDER RELATIONS (CONDUENT)
QUESTIONS?
Wyoming Medicaid will email provider bulletins announcing upcoming
changes and hold training sessions
Do you have more questions about the topics covered during today’s meeting?
Brenda Stout Medicaid Behavioral Health Manager
Wyoming Department of Health
Tel (307) 777-2896