BEHAVIORAL HEALTH PROVIDERS MEDICAID PROVIDER VISITS SUMMER 2017
Brenda Stout Medicaid Behavioral Health Program Manager
TOPICS Behavioral Health Cost Study Next Steps
Applied Behavioral Analysis Fee Schedule
Documentation Standards
Provider Manual
Key Definitions
Questions
Prior Authorization (a.k.a. Cap
Contact Information
Limits) Provider Enrollment Provider Contact Information Retroactive enrollment
Overview
BEHAVIORAL HEALTH MEDICAID COST STUDY
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
OBSERVATIONS REGARDING CURRENT MEDICAID BH RATE STRUCTURE 1
Both CPT and HCPCS are used for some services
2
HCPCS-based payment rates are not associated with professional level
3
Payment and units differ for the same therapy services based on use of HCPCS or CPT codes
4
Multiple HCPCS define the same service
5
Billed and allowed charges are the same for a large proportion of SFY 2016 line items
6
A large proportion of recipients received more than 20 days of service in SFY 2016
7
Unit billing for group therapy was more than expected in SFY 2016
PROPOSED CHANGES The billing/payment issues identified in the previous slides create
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 communitybased setting
RATIONALE
PROPOSED CHANGE
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 • 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 • Currently providers can choose between billing based on the HCPCS-based fee schedule or CPT-based RBRVS fee schedule.
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)
RATIONALE
PROPOSED CHANGES
Pay for assessment and therapy services using the Wyoming RBRVS methodology only (based on CPT code)
• 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
• • •
Varies payment by level of education of professional providing the service Provides consistency with Medicare Responds to provider concerns
Next Steps
BEHAVIORAL HEALTH MEDICAID COST STUDY
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
7/1 2017
2017
10/1 2017
10/1 2018
2018
Post Jan 1, 2019: Implementation and monitoring of rate changes (timing TBD)
12/1 2018
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
1/1 2019
2019
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
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).
Family Therapy: H0004
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
Requirements
DOCUMENTATION STANDARDS
BEHAVIORAL HEALTH DOCUMENTATION STANDARDS 1. Mental health assessment, diagnosis, symptoms and identifying the clinical needs of the client
4. Treatment plan reviews and assessment updates
The Golden Thread
3. Progress towards the identified goals and objectives and notes
2. Goals and objectives that address the concerns of the client
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
Overview
APPLIED BEHAVIOR ANALYSIS TREATMENT
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 ABAIaccredited 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 postdoctoral practical experience to apply for the BCBA examination.
Name
APPLIED BEHAVIOR ANALYSIS PROVIDERS 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
Initial assessment (development of initial treatment plan)
CPT CODE DESCRIPTION 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 nonstandardized 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.
CPT® CODE
0359T (untimed code)
Observational behavioral follow-up assessment includes physician or other qualified health care professional direction with 0360T (initial 30 Observational behavioral follow-up interpretation and report, administered by one technician; first minutes per day) assessment for supervised field work 30 minutes of technician time, face-to-face with the patient. and 0361T (each of assistant behavior analysts and each additional 30 minutes of technician time, face-to-face with additional 30 behavior technicians minutes per day) the patient (List separately in addition to code for primary service)
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)
Adaptive behavior treatment with protocol modification One-on-one ABA intervention to administered by physician or other qualified health care teach/implement a new or modified professional with one patient; first 30 minutes of patient face-totechnique from the treatment plan face time Quarterly meetings between the ABA supervisor, parents/caregivers and assistant behavior analysts/behavior technicians to discuss treatment modifications
each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure)
Once per authorization period
As applicable
As applicable
SERVICES PERFORMED BY
Authorized ABA supervisor
Authorized ABA supervisor or delegated assistant behavior analyst
Assistant behavior analyst or behavior technician under the tiered delivery model, or by the authorized ABA supervisor under the sole delivery model
As applicable
0368T (initial 30 minutes per day) and 0369T (each additional 30 minutes per day)
Transition or discharge reassessments and treatment plan updates
Parent/caregiver(s) training
BILLING FREQUENCY
Quarterly
Authorized ABA supervisor
As applicable Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the 0370T patient present)
As applicable
Authorized ABA supervisor or delegated assistant behavior analyst
Fee Schedule, Provider Manual, etc.
PROVIDER INFORMATION
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 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: Problems
Test Results
Diagnosis
Medications
Family History
Procedures
Immunizations
Alerts
Vital Signs
Allergies/Adverse Reactions
Social History
And more…
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
[email protected]
