Connecticut Medical Assistance Program Policy Transmittal 2014-38 - Connecticut Behavioral Health ...
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Connecticut Medical Assistance Program PB 2014-99
Policy Transmittal 2014-38 December 2014
Effective Date: January 1, 2015
Roderick L. Bremby, Commissioner Contact: William Halsey @ 860-424-5077
TO: Physicians, Physician Groups, APRNs, APRN Groups, Physician Assistants, Behavioral Health Clinicians,
Outpatient Hospitals, Mental Health Clinics, and Enhanced Care Clinic
RE: Autism Spectrum Disorder (ASD) Evaluation and Treatment Services
__________________________________________________________________________________________
The purpose of this policy transmittal is to inform screening tool. The evaluation is intended to rule out
Medicaid enrolled providers that effective January 1, medical or behavioral conditions that may co-occur
2015, the Department will expand its coverage of with ASD or be misinterpreted as ASD. These
Autism Spectrum Disorder (ASD) evaluation and evaluations are provided by a physician, advanced
treatment services for Medicaid enrolled members practice registered nurse (APRN)/nurse practitioner, or
(HUSKY A, C, or D) under the age of 21 for whom physician assistant. These evaluations are billed using
ASD services are medically necessary. existing covered evaluation and management procedure
codes (e.g., 99201-99205, 99211-99215, 99241-99245
The Department is adopting new regulations governing or 99251-99255) available to the appropriate provider.
payment for ASD services provided to Medicaid
members under age twenty-one. The Department Comprehensive Diagnostic Evaluation: This
proposes to amend the Regulations of Connecticut evaluation is a neurodevelopmental review of
State Agencies adding new sections 17b-262-1051 to cognitive, behavioral, emotional, adaptive, and social
17b-262-1065, inclusive. Pursuant to section 17b-10 of functioning, and should use validated evaluation tools
the Connecticut General Statutes, the Department plans in order to diagnose and recommend general ASD
to implement the proposed regulation in draft form as a treatment interventions and issue a comprehensive
binding operational policy, effective January 1, 2015. diagnostic evaluation including an evaluation report.
Please review the Operational Policy carefully. If The comprehensive diagnostic evaluation must be
there is an inconsistency between this Policy performed by a licensed practitioner (e.g. psychiatrist,
Transmittal and the Operational Policy (in the form neurologist, pediatrician including a developmental
of the proposed regulations), the Operational Policy pediatrician, psychologist, licensed clinical social
takes precedence, until the regulations are formally worker) working within his/her scope of practice and
adopted (and will then take precedence). To access who is qualified and experienced in providing ASD
the Operational Policy, go to http://www.ct.gov/dss, evaluation services as defined in section 17b-262-1056
then go to “Publications,” then “Policies and of the proposed regulation.
Regulations,” then “Notices of Intent, Operational
Policies, and Proposed Regulations,” then select the If a member had a previously established ASD
operational policy concerning ASD. diagnosis by a qualified and experienced ASD
evaluator, as described above, the comprehensive
ELIGIBLE MEDICAID MEMBERS diagnostic evaluation need not be repeated, but must be
Individuals eligible for ASD evaluation and treatment confirmed by a licensed practitioner within the
services must be enrolled in Medicaid (HUSKY A, C, previous twelve months. The comprehensive diagnostic
or D) and under the age of 21. evaluation must include a review of the most recent
medical evaluation. The most recent medical
In order for an individual to receive treatment services, evaluation must have been completed in the last twelve
he or she must have a comprehensive diagnostic months. If the practitioner diagnoses the individual
evaluation that recommends ASD services based on an with ASD based on the comprehensive diagnostic
ASD diagnosis consistent with the Diagnostic and evaluation, the practitioner should refer the individual
Statistical Manual for Mental Disorder (DSM 5) for a behavior assessment.
definition of Autism Spectrum Disorder.
Behavior Assessment: A behavior assessment is a
EVALUATION SERVICES clinical compilation of observational data, behavior
Medical/Physical Evaluation: A medical/physical rating scales, and reports from various sources (e.g.
examination is necessary prior to receipt of services to schools, family, pediatricians, etc.) designed to identify
treat ASD. The evaluation will review the individual’s the individual’s current strengths and needs across
overall medical health, hearing, speech, and vision, as developmental and behavior domains. It assesses
appropriate, and should include a validated ASD which autism treatment services would be most
Department of Social Services Division of Health Services 55 Farmington Ave. Hartford, CT 06105
www.ctdssmap.comPolicy Transmittal 2014-38 December 2014 Page |2
appropriate for the individual’s care. Validated includes training for the caregiver to reinforce ASD
assessment tools or instruments must be utilized and treatment services in a clinically effective manner.
can include direct observational assessment,
observation, record review, data collection, and The performing provider shall document the
analysis. The behavior assessment must include the caregiver’s participation in ASD treatment sessions in
current level of functioning using one or more the treatment notes, including the caregiver’s name and
validated data collection instruments or tools. The relationship to the member, date, time, extent and type
assessment must be performed or updated not more of participation.
than six months before treatment services are
requested. Presence or Availability of Caregiver for ASD
Treatment Services
Plan of Care: The practitioner who conducted the In order to ensure ASD treatment services are
behavior assessment will develop a detailed Plan of Medicaid coverable services and do not include non-
Care specifically tailored to each individual that must coverable services such as child care, respite, or related
include, but is not limited, to the following elements: services, a caregiver shall be present or available in the
a) measureable goals and expected outcomes if setting where service are being provided at all times in
treatment services are effective; b) specific description order to care for members under the age of eighteen,
of the recommended amount, type, frequency, setting, even when the caregiver is not directly participating in
and duration of ASD treatment services needed to best the services.
meet the needs of the member; and c) amount and type
of parent/care giver participation required to maximize PROVIDER QUALIFICATIONS AND
success. ENROLLMENT
Practitioners who provide the comprehensive
ASD TREATMENT SERVICES diagnostic evaluation, behavior assessment, and plan of
ASD treatment services include (A) services identified care, and who supervise the treatment intervention
as evidence-based by nationally recognized research services must be enrolled in the Connecticut Medical
reviews, (B) services identified as evidence-based by Assistance Program either as a performing provider
other nationally recognized substantial scientific and associated to a billing provider (such as a group
clinical evidence or (C) any other intervention practice or a clinic) or as an individual billing provider.
supported by credible scientific or clinical evidence, as Providers must work within their scope of practice, and
appropriate to each individual. ASD treatment services have specific experience, training, and specialization in
include a variety of behavioral interventions that meet ASD services.
the criteria in one or more of (A), (B) or (C) above,
such as evidence-based Applied Behavior Analysis Starting January 1, 2015, all BCBAs must be
interventions that meet one or more of those criteria. credentialed in writing by the Department of
The ASD treatment intervention services must be done Development Services (DDS) as meeting the
under the supervision of a qualified licensed applicable qualifications described below. Starting
practitioner working within his/her scope of practice or January 1, 2016, all licensed practitioners who provide
by a qualified Board Certified Behavior Analyst the comprehensive diagnostic evaluation, behavior
(BCBA) working within his/her scope of practice. The assessment, plan of care, and treatment services must
supervising practitioner is responsible for all of the also be credentialed in writing by DDS. All licensed
care provided to the member and for supervising the practitioners performing behavior assessments and
technician and any other support staff. treatment services must still comply with all
qualification requirements described below beginning
Caregiver Participation in ASD Treatment Services January 1, 2015, and the Department or the ASO may
A caregiver (e.g. parent, guardian, family member, request documentation that the provider meets those
babysitter, child care worker, etc.) shall participate in qualifications.
treatment sessions in a manner specified in the
behavioral plan of care that is sufficient to maximize Providers of Comprehensive Diagnostic Evaluations
the quality and clinical effectiveness of the services, as Qualified providers of comprehensive diagnostic
tailored to the needs of each member. Specifically, the evaluations must comply with section 17b-262-1056(c)
caregiver shall participate in at least 50% of all of the proposed regulation. In addition, starting January
treatment sessions, which may be reduced if 1, 2016, all providers of comprehensive diagnostic
appropriate for a member’s unique circumstances in a evaluations must also meet the qualifications set forth
manner that continues to ensure the medical necessity, in section 17a-262-1057(d) of the proposed regulation.
quality and clinical effectiveness of the services, as
documented and explained in the plan of care. The Providers of Behavior Assessments and ASD
caregiver’s participation in ASD treatment sessions Treatment Services
Department of Social Services Division of Health Services 55 Farmington Ave. Hartford, CT 06105
www.ctdssmap.comPolicy Transmittal 2014-38 December 2014 Page |3
Qualified providers of the behavior assessment and a Medicaid enrolled licensed practitioner/provider or
ASD treatment services must possess specialized BCBA who is qualified to provide ASD services.
training, experience or expertise in ASD. Qualified Effective immediately, the technician must meet at
providers include: least the following minimum qualifications as set forth
• Physicians; in section 17a-262-1058(f) of the regulation:
• Advanced Practice Registered Nurses; 1. Education and Experience: Have either (A) A
• Physician Assistants; bachelor’s degree from an accredited college
• Licensed Psychologists; or university in a behavioral health field,
• Licensed Clinical Social Workers; behavior analysis, or a related field, plus one
• Licensed Marital and Family Therapists; year of full-time equivalent experience
• Licensed Professional Counselors; and working with children with a diagnosis of
ASD, or (B) An associate’s degree or an
• Board Certified Behavior Analysts.
equivalent number of credit hours with a
passing grade from an accredited college or
Those providers must meet the requirements set forth
university in a behavioral health field,
in section 17a-262-1057(d) of the regulation.
behavior analysis, or a related field, plus two
Specifically, at least:
years of full-time equivalent experience
1. Training: 18 hours of continuing education in ASD
working with children with ASD; and
services in the last three years, which may include
2. 18 hours of continuing education in ASD
training approved for maintenance of certification
services within the last three years.
for BCBAs, or any appropriate training approved
for license maintenance for any category of
For questions about ASD provider qualification
licensed practitioners listed immediately above;
requirements, please contact the Department of
and
Developmental Services, Division of Autism
2. Professional Experience: Two years of full-time
Spectrum Services at (860) 418-6078.
equivalent work experience in treating individuals
with ASD beginning after the individual graduated
with a degree that made the individual eligible for
PROCEDURE CODES
applicable licensure or certification or the date of
The following procedure codes will be used for all
actual certification, whichever is later; and
providers:
3. ASD Education or Supervised Professional
Experience: All licensed practitioners and BCBAs
Comprehensive Diagnostic Evaluation:
shall meet the requirements of either subparagraph
The Comprehensive Diagnostic Evaluation (CDE)
(A) or subparagraph (B) below:
determines the individual’s diagnosis and makes
A. ASD Education: Passing grades in not less
general ASD treatment recommendations. It can be
than 15 credit hours or the equivalent of
completed in one day or over multiple days. If the
graduate-level courses from an accredited
practitioner diagnoses the individual with ASD based
college or university which, include
on the comprehensive diagnostic evaluation, the
significant content in all of the following:
practitioner should refer the individual for a behavior
ASD treatment, diagnosis and assessment;
assessment to identify more specific interventions
child development; psychopathology; family
which would be useful in treatment.
systems; and multi-cultural diversity and care;
or
There is no HIPAA compliant procedure code
B. Supervised Professional Experience: At least
specifically for a comprehensive diagnostic evaluation
one year of supervised experience under a
of ASD. The most appropriate code found is:
licensed practitioner or a BCBA who is also a
licensed practitioner who meets all of the
0359T- Behavior identification assessment, by the
following (i) works within such individual’s
physician or other qualified health care professional,
scope of practice, (ii) have experience in
face-to-face with patient and caregiver(s), includes
providing applicable ASD services and (iii)
administration of standardized and non-standardized
already meet the requirements of this
tests, detailed behavioral history patient observation
subsection. Supervised professional
and caregiver interview, interpretation of test results,
experience may overlap with one or more
discussion of findings and recommendations with the
years of professional experience described in
primary guardian(s)/caregiver(s), and preparation of
(2) above.
report.
Technician’s Qualifications
This is not a time-based code. The Department will
ASD treatment services may be provided by an
use this code with various modifiers, as described
unlicensed professional under the direct supervision of
below, to reimburse for the CDE. It is understood that
Department of Social Services Division of Health Services 55 Farmington Ave. Hartford, CT 06105
www.ctdssmap.comPolicy Transmittal 2014-38 December 2014 Page |4
based on the clinical presentation and individual about the authorization process can be directed to the
treatment history this evaluation could vary ASO at 877-552-8247.
considerably in duration and be completed in one day
or over multiple days. For a routine evaluation lasting ASD treatment intervention services may be authorized
3-5 hours on a given day the provider should bill using only if the comprehensive diagnostic evaluation
code 0359T without any modifier. This will result in diagnoses the member with ASD and the behavior
payment at the base rate for that provider based on assessment and Plan of Care specifically support the
their licensure/certification. For expanded services, request for authorization as medically necessary.
defined as greater than 5 hours on a single day, the
provider should bill for 0359T with the modifier 22 Comprehensive Diagnostic Evaluation: One unit
(expanded scope). This will increase reimbursement may be authorized per day. Additional units requested
for that day by 50% from the base rate. For reduced will be based on medical necessity. Requests for PA
services, defined as greater than one hour but less than for code 0359T do not need to include the modifier
3 hours the provider should bill for 0359T using the since the provider might not know in advance the
modifier 52 (reduced scope). This will reduce duration of services for any given day. The modifier, if
reimbursement for that day by 50% from the base rate. appropriate, must be included on the claim form and
justified in the medical record.
For any service provided that is less than one hour, the
provider should contact the Administrative Services Behavior Assessment: Behavior assessment
Organization (ASO) to seek authorization for the authorizations will be based on the individual needs of
service that was provided (e.g. psychiatric diagnostic the member. Requests for authorizations should be
evaluation, brief emotional/behavioral assessment with submitted with the number of hours/units the provider
scoring and documentation, per standardized deems necessary to complete the assessment.
instrument, etc.).
Plan of Care: One unit may be authorized to support
If the provider needs more than one day to complete the development of the Plan of Care and medically
the evaluation, the same code and modifiers can be necessary updates to that Plan of Care.
used for each date of the evaluation. For example, if a
provider does a 6 hour evaluation on a single date, they Treatment Intervention Services: All requests for
will bill for 0359T – 22 for that date. If the evaluation treatment intervention services must include a
is done over a period of four hours on the first day and comprehensive diagnostic evaluation performed within
two hours on the second, the provider would bill for the previous twelve months of the authorization request
0359T for the first date and 0359T – 52 for the second for treatment services. Additional information and
date. documentation required includes:
• Requested interventions, types, frequency,
Behavior Assessment intensity, setting, and duration of the services
H0031: mental health assessment by a non-physician. with an explanation and supporting
documentation showing how the specific
For the purposes of ASD services, one hour of requested services are medically necessary;
behavior assessment equals one unit of service.
• the plan of care to support the request for
authorization (completed or updated within
Plan of Care
120 days of the request for treatment
H0032: mental health service plan by a non-physician.
services);
For the purpose of ASD services, development of the • the behavior assessment (described above,
written plan of care equals one unit of service. completed or updated within six months of the
request for treatment services);
Treatment Intervention Services • severity scores, skills-based assessment
H2014: skills training and development, per 15 minutes scores, adaptive scores;
• the most recent medical/physical evaluation
(described above, completed or updated?
AUTHORIZATION OF SERVICES within the last twelve months of the request
All services listed above require prior authorization for treatment services);
(PA) from the Medicaid Behavioral Health • the comprehensive diagnostic evaluation
Administrative Services Organization (ASO). For (described above, completed or updated
information on requesting PA, please refer to Chapter within twelve months of the request for
9, available on the www.ctdssmap.com Web site, by treatment services); and
selecting “Information” and “Publications”. Questions
Department of Social Services Division of Health Services 55 Farmington Ave. Hartford, CT 06105
www.ctdssmap.comPolicy Transmittal 2014-38 December 2014 Page |5
• as applicable, school evaluation and The applicable ASD evaluation and treatment
Individualized Education Program (IEP), intervention reimbursement rates are attached. There
Individual Family Service Plan (IFSP) for are different schedules for:
members under the age of three (3), and any • Physicians, APRNs, and Physician assistants.
other available evaluations or relevant Note that consistent with current policy, the
documents. APRN and PA services are paid at 90% of the
published physician fee schedule amount.
Initial authorization will last for up to forty-five (45) • Psychologists
days in order to determine the quality of the baseline • Behavioral Health Clinicians
data. The first continued stay authorization may be • Behavioral Health Clinics
authorized for up to six (6) months. Subsequent • Board Certified Behavior Analysts
continued stay reviews must include an updated plan of
care that specifically includes progress toward goals on Additional ASD Services Available to Members and
the initial plan of care. After one (1) year of service, Families:
every continued stay review must include a In addition to the Medicaid evaluation and treatment
comprehensive review of goals met, summary of data services described above, the behavioral health ASO
indicating progress toward goals, anticipated benefit of will provide additional support services to members
the intervention for the member, updated Plan of Care, with ASD, including adults and family members.
and the most recent IEP or IFSP, if applicable. Support services include care coordination, family
navigators, and peer specialists. These support services
Supervision: are designed to support the needs of members and/or
All treatment intervention services must be supervised their families in need of ASD services. The ASD Care
by one of the qualified licensed professionals identified Coordination Unit at ValueOptions can be reached by
above working within his/her scope of practice or a calling (877) 552-8247.
BCBA working within his/her scope of practice.
Supervision of staff providing the intervention services DOCUMENTATION
must be done one-to-one and documented in the All services must be documented accurately in the
medical record on a weekly basis for all members in medical record. The documentation in the medical
care. One (1) hour of direct supervision is required for record must include the intervention provided, the
every ten (10) hours of treatment services. Supervision name and credentials and signature of staff performing
must include direct observation of the staff person with the service, the actual time of the service, the location
the member. where the service was provided and the date. The
behavioral health ASO will be responsible for
Special Policy Considerations Based on Provider conducting chart reviews of providers at the outset of
Types: implementation. Chart reviews will include
Currently enrolled licensed CMAP providers may comprehensive diagnostic evaluations, behavior
provide ASD diagnostic, assessment and treatment assessments, plans of care, and treatment progress
services using their existing Medicaid provider notes.
identification number as long as they are operating
within the scope of their license and have the expertise Billing Questions
and experience in providing autism services that are For billing questions, please contact the HP Provider
described in the Provider Qualifications section of this Assistance Center, Monday through Friday from 8:00
policy transmittal. No change to the provider’s a.m. to 5:00 p.m. at 1-800-842-8440.
enrollment is required at this time.
Posting Instructions: Policy transmittals can be
The Department has opened up enrollment for BCBAs downloaded from the Web site at www.ctdssmap.com.
to join the CMAP network effective January 1, 2015.
Specific instructions on the enrollment process for Distribution: This policy transmittal is being
BCBAs will be in a separate transmittal. distributed to providers of the Connecticut Medical
Assistance Program Provider Manual by HP Enterprise
Hospital Outpatient: Since there are no sufficient Services.
appropriate revenue center codes for hospital claims for
each of the ASD diagnostic and treatment services, Responsible Unit: DSS, Division of Health Services,
physicians within a hospital outpatient program will be Integrated Care Unit, William Halsey at (860) 424-
required to use their physician group practice provider 5077.
type/specialty in order to submit claims.
Date Issued: December 2014
REIMBURSEMENT RATES
Department of Social Services Division of Health Services 55 Farmington Ave. Hartford, CT 06105
www.ctdssmap.comAutism Spectrum Disorder (ASD) Reimbursement Rates Effective 1/1/15
Billing Provider Type
Code Description Units MD APRN/PA Psychologist BH Clinic LCSW/LMFT/LPC BCBA
0359T Diagnositc eval (3-5 hrs) $ 720.00 $ 648.00 $ 612.00 $ 612.00 $504 (LCSW only) n/a
One Per day of
0359T-22 Expanded Eval (5 or more hrs) $ 1,080.00 $ 972.00 $ 918.00 $ 918.00 $756.00 (LCSW only) n/a
one of these
0359T-52 Reduced Eval ( 1-3 hrs) $ 360.00 $ 324.00 $ 306.00 $ 306.00 $252.00 (LCSW only) n/a
H0031 Behavior Assessment Per Hour $ 112.00 $100.80 $ 95.20 $ 78.40 $ 78.40 $ 78.40
H0032 Treatment Plan development Per Plan $ 112.00 $ 100.80 $ 95.20 $ 78.40 $ 78.40 $ 78.40
H2014 Treatment services Per 15 minutes $ 14.12 $ 12.70 $ 12.00 $ 12.00 $ 9.88 $ 12.00You can also read
