Department of Medical Assistance Services

Department of Medical Assistance Services CHILDREN’S COMMUNITY MENTAL HEALTH SERVICES: Therapeutic Day Treatment H0035HA WebEx Training May 2010

************ This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals Training material contains only highlights of manuals and is not meant to substitute for or take their place For a complete copy of any manual: www.dmas.virginia.gov

Therapeutic Day Treatment for Children & Adolescents(H0035HA) SERVICE DEFINITION • Psychotherapeutic interventions services combined with medication education and mental health treatment • Offered in programs of 2 or more hours per day with groups of children/adolescents (up to the age 21 as EPSTD service)

Therapeutic Day Treatment for Children & Adolescents (H0035-HA) • If a child or adolescent has co-occurring mental health and substance abuse disorders, integrated treatment is allowed within TDT services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. • The impact of the substance abuse condition on the mental health condition must be documented in the treatment plan and the progress notes.

TDT Licensure by Department of Behavioral Health and Developmental Services (DBHDS): • Therapeutic Day Treatment providers for children and adolescents must be licensed as a provider of Day Treatment Services by DBHDS.

Does the childmeet the eligibilitycriteriafor the service?

TDT Eligibility Criteria: Individual demonstrates a: • Mental, behavioral or emotional illness resulting in significant functional impairments in major life activities • Impairment has become more disabling over time (with in the past 30 days) • Require significant intervention services offered over a period of time that are: • Supportive & Intensive

TDT Eligibility Criteria (cont’d): Individuals must meet at least two on a continuing or intermittent basis (within the past 6 months) and the support for this must be clearly documented in the medical record with child-specific examples: 1. Difficulty in establishing or maintaining normal interpersonal relationships (at risk of hospitalization or out-of-home placement because of conflicts with family/community)

TDT Eligibility Criteria (cont’d): 2. Exhibit inappropriate behavior: Repeated interventions required by the community by mental health agencies by social service agencies by judicial system (For example, crisis intervention services have been provided, or outside intervention for truancy has been made)

TDT Eligibility Criteria (cont’d): 3. Exhibit difficulty in cognitive ability: such that they are unable to recognize personal danger OR significantly inappropriate social behavior An out-of-home placement (at risk of) is defined as one or more of the following: • Level A or Level B group home • Regular foster home (if currently residing with biological family and due to behavior problems is at risk of move to DSS custody) • Treatment foster care placement (if currently residing with biological family or a regular foster family and due to behavior problems is at risk of move to higher level of care)

TDT Eligibility Criteria (cont’d): • Level C residential facility • Emergency shelter (for child only, due to MH/behavioral problems), • Psychiatric hospitalization, juvenile justice/incarceration placement (detention, corrections)

TDT Eligibility Criteria (cont’d): • In addition to meeting two of the three criteria listed above, children and adolescents must meet one of the following that must be supported by child-specific documentation in the medical record: • Require year-round treatment (9-12 months) in order to sustain behavioral or emotional gains. (the medical record must document the need for year-round treatment and any periods when service has been decreased and behavioral or emotional gains have been lost and/or improved) . or

TDT Eligibility Criteria (cont’d): • Have behavior/emotional problems so severe they cannot be handled in self-contained or special classrooms (ED) without this programming during the school day or as a supplement to the school day/year (medical record must document the type of classroom program(s) unable to meet the child’s needs, specifically why the needs are not able to be met and how the problem behaviors are exhibited), or • Would otherwise be placed on homebound instruction because of severe behavior problems (medical record must contain documentation from the school staff that supports this criterion), or

TDT Eligibility Criteria (cont’d) Have deficits in: • social skills • peer relations • dealing with authority • are hyperactive • have poor impulse control • are extremely depressed • marginally connected with reality (These behaviors must be documented in the medical record and describing the level they significantly impact the child’s abilities to participate in activities of daily living compared to most children who are the same age)

TDT Eligibility Criteria (con’t) or • Preschool child in an enrichment & early intervention program that cannot function in this program (due to the severity of their emotional/behavioral problems) without these additional services • Medical record must clearly document the severity of the problems and how they impact participation in the preschool or intervention programs)

TDT Required Activities: Before service initiation: • A face-to-face diagnostic assessment is completed minimally by a QMHP with review & approval by LMHP prior to service initiation. • The assessment must be reviewed and updated at least annually. PA is not required for assessment

Assessment Code for TDT: • The Assessment billing code is H0032 Modifier U7 • Assessment codes never require PA • Limit is 2 per recipient per provider per fiscal year • Used for new and existing recipients (initial and reassessment) • Provider bills assessment code with modifier for 1 unit. (H0032 Modifier U7) • Reimbursement allowed is a flat rate of $38.05/unit

New Recipients / Clients: • Individuals who have not had TDT treatment January 1, 2009 and dates forward are considered new admission cases. • Must bill the appropriate assessment code (with modifier) to determine needs (H0032 Modifier U7) • The provider gets 5 units without PA only first time in treatment.

New Recipients / Clients: • If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments • Provider bills assessment, then bills 5 units without PA • Bills the remaining units with PA #

New Recipients / Clients: • Must submit a PA request to KePRO after the assessment and before the 5 units without PA are used • If there is no PA after the 5 units are used --- claims will deny

Existing Recipients: • Individuals currently receiving TDT services are defined as those that have claims activity in MMIS with DOS on or after January 1, 2009. • System edit will look to see if previous TDT service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for “existing recipients” • May bill for “reassessment” to determine continued need for services (2 per provider per recipient per fiscal year for each service and does not require PA)

TDT Required Activities: • An Individualized Service Plan (ISP) indicating all entities participating in active treatment must be completed by a QMHP documenting the need for services within 30 days of service initiation. • The ISP must be cosigned by the recipient or legal guardian.

TDT ISP Requirements: • Comprehensive and regularly updated (based in treatment need changes) • Specific to individual being treated • Containing goals and measurable objectives to meet identified needs • Services to be provided with recommended frequency to accomplish the measurable goals and objectives • Estimated timetable for achieving the goals and objectives • Maintained up to date as the needs and progress of the individual changes,

TDT ISP DO’s: • INDIVIDUALIZED! • Include all service needs identified in assessment • Objectives = specific desired client behaviors in quantitative terms • Interventions = specific planned staff actions with a specific planned frequency • Services must be provided according to the ISP (minimally by QPPs under the supervision of a QMHP)

TDT Required Activities (con’t) • The program must operate a minimum of 2 hours per day and may offer flexible program hours (before/after school, summer) • The staff case load to recipient ratio is 1:6 • Coordination with the Case Management Agency (if applicable) • Services must not duplicate services provided by school • At a minimum, services are provided by qualified paraprofessionals under the supervision of a QMHP.

TDT Required Activities (cont’d) Direct services include individual and group activities. • Individual activities can include one-to-one counseling, working side by side with the student in a classroom, or direct observation in a classroom. • If the recipient is on medication, education about side effects, monitoring of compliance and referrals for routine physician follow up must be provided to the child/adolescent and parent/ guardian and documented. Response to medication and education, as well as compliance must also be documented.

TDT Required Activities (cont’d) • Group activities can include psycho-educational groups such as anger management, community responsibility, problem solving, or positive peer relations. (limited to not > 10)

TDT Required Activities (cont’d) • Indirect services can include the time the staff is not in the classroom, but there must be documentation of consultation with school staff and the child to determine progress towards goals in the ISP and ongoing therapeutic behavioral intervention needs. • Indirect service also includes coordinating time with the case management agency, if any.

TDT Required Activities (con’t) • Minimum billing is 2 hrs per day (1 Unit). One hour must be direct face-to-face, the other hour may be indirect; • A minimum of 2 therapeutic activities must occur per day; • Family contacts (in person or telephone) must occur at least weekly;

TDT Required Activities (con’t) • Progress notes are completed on a weekly basis at a minimum • There needs to be a daily written summary of service provided. Summary must include description of child’s behavior, staff interventions & child’s response to interventions. • Summary must support time billed;

TDT Required Activities (cont’d) • Progress note documentation must include: • Name of service rendered • Date service rendered • The setting • Signature/credentials of person rendering service • Amount of time/units delivered (start & stop time is recommended)

TDT Progress Note DO’S: • Be sure to include ALL billable services provided to correlate with time billed • Address all ongoing needs from the ISP • Describe the specific client behaviors, what staff did, and clients’ responses • Document weekly communication/counseling with parents • Academic instruction, tutoring, and functioning as a school aide are not billable • Duplicate notes are not billable—services must not duplicate those provided by the school

Service Units & Limitations: Services are limited annually to 780 units per year. Starting August 1, 2009 and each July 1st thereafter, all service limits will be set to zero. • The fiscal year period for the start up of this process will be August 1, 2009 through June 30, 2010. All subsequent fiscal years will be July 1 through June 30.

Service Limits and Limitations One Unit of service is defined as a minimum of two hours on a given day:

TDT Limitations: • Time for academic instruction when no treatment activity is going on cannot be included in the billing unit • Staff travel time is excluded

Prior Authorization Process for TDT • Effective August 1, 2009 Prior Authorization requirements were implemented. • For new clients– after assessment --providers have five units to begin providing service. For any services to be paid beyond five units a PA is required.

Prior Authorization Requirements: • The provider will need to submit recipients demographic information & also include the following: • Procedure Code – H0035 • PA Service Type - 0650 • Number of units requested • From (date is after the 5 units are used) & Through dates (span 6 months)

Initial Review (New Recipient to Provider): • For TDT, individuals must DSM IV Axis I Mental Health Disorder. • Describe symptoms/severity of illness: Children must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness, which has become more disabling over time.

Initial PA Request cont’d. • Must describe how meets two of the following: • Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization or out of home placement; or • Have behaviors that require repeated interventions by the mental health, social services or judicial system; or • Be unable to recognize personal danger or significantly inappropriate social behavior.

Initial PA Request cont’d. Must describe how meets one of the following: • Requires year-round treatment to sustain behavioral or emotional gains; or • Have problems so severe cannot be maintained in self-contained or resource (ED) classrooms without programming during the school day or as supplement to school day; or • Would otherwise be placed on homebound instruction due to severe emotional or behavioral problems that interfere with learning; or • Have emotional or behavioral problems so severe the child cannot function in preschool enrichment or early intervention programs without additional services.

Initial PA Request cont’d. Have deficits in: • social skills • peer relations • dealing with authority • are hyperactive • have poor impulse control • are extremely depressed • marginally connected with reality

Initial PA Request cont’d. • KePRO will prior authorize services in 6 month increments • Initial requests will be approved (based on the medical necessity) for up to one half the service units available. • PA requests after denials of services for medical necessity may be resubmitted at a later date if the individual later meets criteria

PA For Continued Treatment: • For TDT, individuals Axis I Mental Health Disorder. V codes are not acceptable as stand alone diagnoses.MUST describe how continues to meet two of the following: • Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization or out of home placement; or • Have behaviors that require repeated interventions by the mental health, social services or judicial system; or • Be unable to recognize personal danger or significantly inappropriate social behavior.

PA For Continued Treatment: • Must describe how individual continues to meet one of the following: • Requires year-round treatment to sustain behavioral or emotional gains; or • Have problems so severe cannot be maintained in self-contained or resource (ED) classrooms without programming during the school day or as supplement to school day; or

PA For Continued Treatment: • Would otherwise be placed on homebound instruction due to severe emotional or behavioral problems that interfere with learning; or • Have emotional or behavioral problems so severe the child cannot function in preschool enrichment or early intervention programs without additional services.

PA For Continued Treatment: Continue to have deficits in: • social skills • peer relations • dealing with authority • are hyperactive • have poor impulse control • are extremely depressed • marginally connected with reality

PA For Continued Treatment: • Continued service requests will be approved for up to 6-month increments for the remaining annual service limit. • PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria • PA requests may be made up to 30 days in advance

Submitting a Prior Authorization (PA) Request via iEXCHANGE® • The preferred method for submitting a PA request is the iEXCHANGE® web-based program • Registration required • Information may be found by going to the KePRO website https://dmas.kepro.org For questions call 1-888-827-2884 or email at ProviderIssues@kepro.org

Email any questions related to Behavioral Health Policy to: CMHRS@DMAS.Virginia.gov

Thank You! www.dmas.virginia.gov

Department of Medical Assistance Services