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Behavioral Health
Behavioral Health
bcbsks.com
An independent licensee of the Blue Cross Blue Shield Association.BEHAVIORAL HEALTH – Table of Contents Table of Contents I. Eligible Providers and Facilities ......................................................................................................... 4 II. Benefits .............................................................................................................................................. 4 III. Documentation Guidelines................................................................................................................. 4 IV. Limited Patient Waiver ..................................................................................................................... 10 V. Medical Necessity ............................................................................................................................ 11 VI. Utilization Management ................................................................................................................... 11 VII. BCBSKS/ NDBH Authorization Process .......................................................................................... 14 VIII. Diagnoses ........................................................................................................................................ 17 IX. Outpatient Coverage for Mental Conditions .................................................................................... 19 X. Behavioral Health Intensive Outpatient Program (IOP)................................................................... 20 XI. AMA CPT Evaluation & Management Codes, Psychiatric Codes & Guidelines ............................. 24 XII. Coding.............................................................................................................................................. 27 XIII. Telemedicine Services..................................................................................................................... 32 Revisions ..................................................................................................................................................... 34 Contains Public Information 2 Revision Date: January 2019
BEHAVIORAL HEALTH – Guidelines
This appendix to the Professional Provider Manual briefly describes the mental health benefits
and guidelines available to the members of Blue Cross and Blue Shield of Kansas. The
information applies specifically to those providing mental health services, on an inpatient and
outpatient basis.
Acknowledgement – Current Procedural Terminology (CPT®) is copyright 2018 American
Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative
values or related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable – ARS/DFARS Restrictions Apply to Government Use
NOTE – The revision date appears in the footer of the document. Links within the document
are updated as changes occur throughout the year.
3 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
I. Eligible Providers and Facilities health nursing or related mental health
field
Blue Cross and Blue Shield of Kansas
8. Autism Specialist (AS)
(BCBSKS) reimburses outpatient mental
9. Intensive Individual Support Provider
health services provided by the following
(IIS)
types of providers and facilities, as
10. A hospital
recognized by the member's contract.
11. A state-licensed Medical Care Facility,
Providers who are unlicensed or who are
defined as:
not included among the covered providers
a. A psychiatric hospital
listed below will not be reimbursed for
b. A community mental health center
psychotherapy or any other services
connected with a mental diagnosis.
II. Benefits
Supervision of an unlicensed provider or a
provider not listed below does not For eligibility and benefit verification
constitute a service being rendered by an regarding SPECIFIC contracts and/or
eligible provider. groups, providers are encouraged to
1. A licensed Doctor of Medicine, or look up information at Availity.com.
Doctor of Osteopathy
Through Availity, providers can access
2. A Clinical Psychologist (PhD or PsyD)
licensed to practice under the laws of both the Availity web portal and
the State of Kansas BlueAccess – BCBSKS's secure web
3. A licensed Social Worker authorized to portal – to view secure BCBSKS
engage in private independent practice member claims and eligibility
(LSCSW) under the laws of the State of information.
Kansas
The BCBSKS Provider Benefit Hotline in
4. Licensed Clinical Marriage and Family
Topeka can be reached at 785-291-4183
Therapist (LCMFT)
or 800-432-0272.
5. Licensed Clinical Professional
Counselor (LCPC)
III. Documentation Guidelines
6. Licensed Clinical Psychotherapist
(LCP) The importance of having the services
7. An Advanced Practice Registered performed sufficiently documented cannot
Nurse (APRN), with a minimum of a be over-emphasized.
master's degree in psychiatric/mental
Contains Public Information 4
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
The following medical record standards 4. Contain pertinent and significant
are minimally required, and if not met, information concerning the patient's
may result in a claim denial and presenting condition. This should
accordingly a provider write-off. include:
• Documentation of at least one mental
Records must:
health status evaluation (e.g. patient's
1. Be legible in both readability and
affect, speech, mood, thought
content. If not readable, reimbursement
content, judgment, insight, attention
will be denied.
or concentration, memory, and
2. Contain only those terms and
impulse control).
abbreviations easily comprehended by
• Documentation of past and present
peers of similar licensure. If a legend is
use of tobacco, alcohol and
needed to review your records, please
prescribed, illicit, and over the
submit it with your records. If needed
counter drugs, including frequency
and you have not submitted one, Blue
and quantity.
Cross Blue Shield of Kansas may
• Psychiatric history which includes:
request you provide a legend. If not
o Previous treatment dates
supplied upon request reimbursement
o Therapeutic interventions and
will be denied.
responses
3. Contain personal/biographical
o Sources of clinical data (e.g., self,
information in a consistent location
mother, spouse, past medical
including the following:
records)
• Name (first and last) – should be
o Relevant family information
reflected on every page
o Consultation reports including
• DOB (date of birth) – should be
psychological and
reflected on every page
neuropsychological testing (if
• Home Address
available/applicable)
• Home/work telephone numbers
o Laboratory test results if applicable
• Employer or school name
in physician and nurse practitioner
• Marital or legal status
records
• Medication allergies with reactions
• Medication management including
• Appropriate consent
medication prescribed; quantity or
forms/guardianship information
documentation of no medication; and
• Emergency contact information over the counter medication. For
5 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
physician and nurse practitioners, this estimated time frames for goal
should also include the dosages and achievement, and documentation of the
usage instructions of each medication patient's strengths and limitations in
and the dates of initial prescription achieving the goals. The treatment plan
and/or refills. should be individualized for each
5. Indicate the initial diagnosis and the patient. Document the patient's
patient's initial reason for seeking the progress during the course of treatment
provider's care. The diagnosis is not as it relates to the plan of care and
just an /ICD-10-CM billing code, but a diagnosis. Continuity and coordination
written interpretation of the patient's of care should be reflected in the
condition and physical findings. The medical record, including
diagnosis should be recorded in the communication with or review of
record and reflected on the claim form. information from other behavioral
6. Document the treatment provided. This health professional, ancillary providers,
would include the dates any primary care providers, and health care
professional service was provided. List institutions. Referrals to community
start and stop times or total time on all outreach services and higher levels of
timed codes per CPT nomenclature. If care should be documented.
dates of services and/or start/stop (or 8. Medical records of minor patients
reference to total time) are not (under age 18) should contain
recorded, reimbursement may be documentation of prenatal and parental
reduced. Group documentation must events, along with complete
indicate each specific encounter for the developmental histories and evidence
date of service and each session of family involvement. Parental
attended not a collective summary for informed consent for all prescribed
multiple sessions or dates of service. medications should be included.
Documentation should include duration 9. Signature Requirements — In the
and purpose of the group and medically content of health records, each entry
necessity as indicated by the patient's must be authenticated by the author.
individual treatment plan. Authentication is the process of
7. Treatment Plan: The treatment plan providing proof of the authorship
contains specific measurable goals, signifying knowledge, approval,
documentation of the treatment plan acceptance or obligation of the
and/or goals discussed with the patient, documentation in the health record,
Contains Public Information 6
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
whether maintained in a paper or Doe, M.D. on MM/DD/YYYY at
electronic format accomplished with a XX:XX A.M.
handwritten or electronic signature. c. A digital signature is a digitized
Individuals providing care for the version of a handwritten signature
patient are responsible for on a pen pad and automatically
documentation of the care. The converted to a digital signature that
documentation must reflect who is affixed to the electronic document.
performed the service. The digital signature must be legible
a. The handwritten signature must be and contain the first and last name,
legible and contain at least the first credentials, and date.
initial and full last name along with d. Rubber stamp signatures are not
credentials and date. A typed or permissible. This provision does not
printed name must be accompanied affect stamped signatures on claims,
by a handwritten signature or initials which remain permissible.
with credentials and date.
Documentation Errors
b. An electronic signature is a unique
Listed below are a few documentation
personal identifier such as a unique
errors that are commonly missed.
code, biometric, or password
• Start and stop times or duration
entered by the author of the
o Not listing start and stop times or
electronic medical record (EMR) or
duration – Most CPT codes are time
electronic health record (EHR) via
sensitive. It is good practice to
electronic means, and is
document the face-to-face time
automatically and permanently
and/or duration you spend with the
attached to the document when
patient.
created including the author's first
and last name, with credentials, with • Treatment planning
automatic dating and time stamping o Indicate if you made changes to the
of the entry. After the entry is treatment plan goals or if the goals
electronically signed, the text-editing remain unchanged.
feature should not be available for • Follow up appointments
amending documentation. Example o It is important to indicate when the
of an electronically signed signature: next appointment is and, as
"Electronically signed by John appropriate, any discharge planning.
7 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
• Patient's presentation Objective notes should reflect the
o Reflect the patient's presentation in following:
each face‐to‐face encounter note. • Visual observation
This should contain objective and • Reports from other
subjective documentation of the counselors/therapists
patient’s presentation. • Results of psychological tests and
• Diagnosis widely accepted scales to measure the
o Be precise. Update as appropriate. effectiveness of care (i.e. Beck
• Documentation Depression Inventory, Hamilton
o Documentation must match the Depression Rating Scale, etc.)
requirements of the CPT code. • Quantifiable terms
Please refer to the most current CPT
Assessment notes should include the
code book for specific requirements.
following:
Also, at www.ndbh.com provider tab,
• Initial evaluation
there is documentation on how to
• Short term goals
determine what codes are most
appropriate. • Long term goals
• Overall progress
SOAP Note Format
It is essential for the provider to document Plan notes should include the following:
clinical notes and findings to support • Referrals
medical necessity. A format that may be • Interventions
used is a SOAP note. SOAP stands for • Anticipated discharge or referral
Subjective, Objective, Assessment, and • Recommendations
Plan. • Prognosis with regard to the treatment
plan
Subjective notes should reflect the
following: Psychotherapy Notes
• Patient's reason for seeking care vs. Progress Notes
• Duration of complaint Maintaining medical records is a standard
• Past medical history and treatment part of any mental health practice. Mental
history health records have additional protections
• Social history, tobacco use, alcohol not provided to other practices. The health
use, substance abuse, illicit drug use Insurance Portability and Accountability
Act (HIPAA) Privacy Rule requires
Contains Public Information 8
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
psychotherapy notes receive the highest Psychotherapy Notes
level of protection. Psychotherapy Notes should not be
incorporated into the medical record.
Psychotherapy notes are different from
Psychotherapy notes are for the provider's
progress notes in critical ways. The key
own use in conceptualizing the case.
differences between the two are outlined
below to keep in mind when documenting Unlike progress notes, psychotherapy
the next session. notes may include analyses of the
contents of a conversation from a private
Progress Notes
counseling session, the provider's
One key difference between progress
thought, feelings and impressions about
notes and psychotherapy notes is
the case, theoretical analysis of the
progress notes are subject to being
session, and hypotheses to further
shared with insurance companies,
explore in future sessions with the client.
additional providers who share treatment
of the client, and other outside parties. As As long as these notes are kept separate
explained in the HIPAA Privacy Rule 45 from the medical record, the notes fall
CFR 164.501, progress notes may include under the protection of the HIPAA Privacy
the documentation of medication Rule and cannot be released without
prescription and monitoring, counseling specific authorized written consent form
session start and stop times, the the client.
modalities and frequencies of treatment
Keeping it separate
furnished, results of clinical test, and any
A big challenge for providers is keeping
summary of the following items: diagnosis,
psychotherapy notes separate from
functional status, the treatment plan,
progress notes. Providers often keep just
symptoms, prognosis, and progress to
one note that documents the session with
date.
their client.
Progress notes also may include a brief
It is vital for providers to understand that
description of the topics discussed,
psychotherapy notes need to be
treatment interventions that were used,
documented and stored separately from
and observations and assessment of the
the progress notes and from the medical
client's status.
record.
9 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
The elements in a psychotherapy note are NOTE – The waiver form cannot be
not required to support medical necessity utilized for services considered to be
of a service and claims billed. In contrast, content of another service provided.
the elements in the progress note do.
Situations Requiring a Waiver
1. Medical necessity denials
IV. Limited Patient Waiver
2. Utilization denials
Occasionally BCBSKS does not consider 3. Patient demanded services
an item or service to be medically 4. Experimental/investigational
necessary. In such situations the item or procedures
service becomes a provider write-off 5. HighTech Option is used when a
without advance notice to the patient. In patient requests the provider not file a
the few situations where services are claim for services to their insurance.
known to be denied as not medically Member agrees to pay for the service,
necessary and the patient insists on the and acknowledges they have no appeal
services, the provider must obtain a rights. Option 2 on the waiver form
patient waiver of liability in advance of the must be completed and signed.
services being rendered, in order for the
patient to be held financially responsible. The Waiver Form Must Be:
In these cases, a GA modifier should be 1. Signed before receipt of service.
added to the service on the claim 2. Patient, service, and reason specific.
submission to indicate a valid waiver of 3. Date of service and dollar amount
liability has been signed by the patient. specific.
Failure to discuss the above with the 4. Retained in the patient's file at the
patient in advance and obtain the waiver provider's place of business. (The
will result in a provider write-off. waiver form is no longer required with
claims submission).
For an example of the Limited Patient
5. Add a GA modifier for all electronic and
Waiver Form, please refer to Policy Memo
paper claims.
No. 1, Section X. A sample waiver form
6. Presented on an individual basis to the
can also be found after the last page of
patients. It may not be a blanket
Policy Memo No. 1 and also on the
statement signed by all patients.
bcbsks.com website under "Forms."
7. Acknowledged by patient that he or she
will be personally responsible for the
amount of the charge, to include an
Contains Public Information 10
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
approximate amount of the charge at available at:
issue. https://www.ndbh.com/Providers/Behavior
NOTE – If the waiver is not signed alHealthPlanProviders.aspx
before the service is rendered, the
service is considered a contracting VI. Utilization Management
provider write-off, unless there are
New Directions Behavioral Health
extenuating circumstances.
BCBSKS contracts with New Directions
Behavioral Health (NDBH) to perform
V. Medical Necessity utilization and medical necessity
Medical necessity is a requirement of determinations for behavioral health
good stewardship of member premiums claims.
and is a standard of care that is supported
NDBH provides the following services:
by the behavioral health professional as
1. Precertification reviews for
well as all payor sources. Documentation
approval/denial of pre-admission
must support the renderence and medical
certification requests for inpatient
necessity of the service billed.
hospitalizations and partial-day
Medically Necessary describes a service treatment, determining appropriateness
or supply performed, referred or by utilizing established criteria
prescribed by a provider in the most 2. Concurrent review of length of stay
appropriate setting and consistent with the authorizations
diagnosis and treatment of the patient's 3. Retrospective review of claims not prior
condition in accordance with generally authorized
accepted standards of medical practice in 4. Appeals review and reconsideration
the United States based on credible 5. Review of outpatient treatment plans
scientific evidence and not primarily for for medical necessity as specified by
the convenience of the patient, physician plan directives
or other health care provider. Services 6. Review of Behavioral Health IOP
must be considered effective to improve protocols
symptoms associated with patient's 7. Review of the following services for
illness, disease, injury or deficits in medical necessity and appropriateness:
functioning. • Psychological testing
• Autism services
A copy of the medical necessity criteria
and other information for providers is
11 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
• Electroconvulsive Therapy (ECT) implementation of an individualized
(90870) treatment plan.
• Intensive Outpatient (IOP) 5. Family participation:
All BCBSKS policies and those secondary a. For adults – Family treatment is
to Medicare, are subject to NDBH's being utilized at an appropriate
review. There are limited exceptions, frequency. If family treatment is not
including Plan 65, and out-of-state held, the facility/provider specifically
policies. lists the contraindications to Family
Therapy.
Psychiatric Outpatient Criteria
b. For children/adolescents – Family
Intensity of Service
treatment will be provided as part of
Must meet all of the following:
the treatment plan. If Family
1. Treatment is provided by either a
treatment is not held, the
licensed practitioner or
facility/provider specifically lists the
licensed/accredited clinic and complies
contraindications to Family
with generally accepted standards of
Therapy. The family/support system
care within the provider's scope of
assessment will be completed
training/licensure.
within diagnostic evaluation phase
2. Coordination with other behavioral and
of treatment with the expectation
medical health providers as
that family is involved in treatment
appropriate, but with a minimum
decisions and discharge planning
recommended frequency of every 60
throughout the course of care.
days.
c. Family participation may be
3. Individualized treatment plan that
conducted via telephonic sessions.
guides management of the member's
care. Treatment provided is timely, Admission Criteria
appropriate, and evidence-based), POP must meet items 1 - 4 and either 5,
including referral for both medical 6, 7 or 8:
and/or psychiatric medication 1. A DSM diagnosis is the primary focus
management as needed. of active treatment.
4. Recent treating providers are contacted 2. There is a reasonable expectation of
by members of the treatment team to reduction in behaviors/symptoms with
assist in the development and the proposed treatment at this level of
care.
Contains Public Information 12
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
3. The treatment is not primarily social, 7. The member requires intensive support
custodial, interpersonal, domiciliary or to ensure compliance with medications
respite care. and/or treatment recommendations.
4. There is documented evidence of the 8. The member is engaged with or needs
need for treatment to address the assistance engaging with multiple
significant negative impact of DSM providers and services, and needs brief
diagnosis in the person’s life in any of intervention (including in-home
the following areas: a. Family b. services) to ensure coordination and
Work/school c. Social/interpersonal d. continuity of care amongst the
Health/medical compliance providers and services.
5. The member requires ongoing
Benefit Denial Reasons
treatment/intervention in order to
1. Despite intensive efforts, the member
maintain symptom relief and/or
refuses to cooperate with the treatment
psychosocial functioning for a chronic
plan and there is no longer a
recurrent mental health illness.
reasonable expectation of reduction in
Treatment is intended to prevent
symptoms/behavior with treatment at
intensification of said symptoms or
this continued level of care.
deterioration in functioning that would
2. There is significant documented
result in admission to higher levels of
reduction in the intensity, duration and
care.
frequency of the symptoms/behaviors
If in-home therapy is requested, must that resulted in the admission so that
additionally meet 6 through 8: the member's current behaviors and
6. The member is experiencing an acute symptoms meet criteria for another
crisis or significant impairment in level of care.
primary support, social support, or 3. The member has completed treatment
housing, and may be at high risk of goals as outlined in the master
being displaced from his/her living treatment plan or has reached
situation (e.g., interventions by the maximum benefit from the treatment.
legal system, family/children services
or higher levels of medical or
behavioral health care).
13 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
VII. BCBSKS/ NDBH Authorization outcomes. Utilization will be compared
Process based upon the mix of patient and case
Authorization is required for the following characteristics. Additional objectives are:
services: • To establish a partnership with
• Autism services (See separate Autism providers to positively impact the
manual) patient's experience in receiving
• Electroconvulsive Therapy (ECT) outpatient behavioral health services.
(90870) • To provide information on practice
Authorization is recommended for guidelines to providers.
psychological testing needing more • To improve the efficiency of outpatient
than five hours. behavioral health services.
• To identify and connect patients with
Upon receiving an authorization request additional support resources.
for treatment, NDBH will make a • To identify and reduce health-care
determination based on the clinic spending that does not improve the
information provided by the provider. It is outcome.
in the best interest of the provider to notify
• To decrease variation in patterns of
NDBH of any service request prior to
care not associated with differing
beginning treatment (if possible) as this
clinical outcomes.
will allow for clarifications regarding
• To provide education and solicit
member benefits, and possible non-
feedback to promote alignment in
covered services.
practice patterns.
For services approved, denied, or
Providers whose practice patterns vary
extended, letters will be mailed and/or
significantly from their peer group will
faxed.
undergo review based on Medical
NDBH will analyze claims data for all Necessity Criteria. If such review
behavioral health providers in the determines services provided are not
BCBSKS network. As we identify medically necessary, providers may be
variances in practice patterns, we will referred for an ongoing review process.
share information and educational Services denied under this review process
materials with you. The goal is to ensure also may result in recoupment of payment
appropriate utilization and reduce outlier if denied as not medically necessary. This
variation while supporting quality approach is consistent with how reviews
Contains Public Information 14
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
are handled for medical service providers • WebPass allows providers to see an
as well. approval or requests for additional
information. You can answer the
On behalf of BCBSKS, one way NDBH
questions electronically and resubmit
will review claims is to request treatment
them.
records (progress notes) for specific
• Letters received from BCBSKS
patients. When requested, the treatment
requesting progress notes will require
records should be sent to NDBH within
you to resubmit a new claim for the
the time allowed. NDBH will not be
date of service and provide an
requesting private psychotherapy notes,
OVERVIEW or SUMMARY for the date
which should be separate from the
of service to support medical necessity
treatment records. Even if there is no
and services provided.
authorization required for treatment,
• Letters are sent when a current
documentation is still required.
authorization is not in place to cover
Process for services requiring Clinical the date of service. This information
Review Forms: should be sent to BCBSKS Customer
• Request submitted via WebPass Service department. Information is then
• Clinical Review forms can be imaged on to NDBH for review and
completed electronically via WebPass authorization.
process. • When completing Clinical Review Form
• To access WebPass, go to through WebPass, keep your clinical
www.ndbh.com, follow the Provider link records handy so you can provide all
to BCBSKS, Provider WebPass. the information requested.
• Additional Sessions required – Submit
WebPass Clinical Review Process
a new Clinical Review Form via
WebPass is the preferred and most
WebPass with start dates identified.
efficient way to request authorizations.
Otherwise, the date the provider signs
the Clinical Review form is the date In order to request authorizations from
used to begin the next authorization. New Directions, please use the
• Approval – NDBH will mail and fax your appropriate Clinical Review form, which is
approved authorizations, with the start available at www.ndbh.com.
and end date. PROVIDERS will need to • Authorization for Admission to Care,
track visits for future authorizations. use Initial Review.
15 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
• Authorization for Ongoing Care • Before selecting a Clinical Review
Request and Care Coordination, use: form, you will need to first look up a
o Discharge Clinical Review member.
o Concurrent Review • You will then access the Clinical Forms
link, and begin the authorization
To use WebPass
process.
Providers/facilities must sign up using the
following instructions: NDBH Customer Service 800-952-5906
• Send an email to New Directions with NDBH Fax 816-237-2364
the name of the administrator for your
Psychological and Neuropsychological
group. The administrator will then be
Testing Criteria
responsible for managing facility users,
Intensity of Service
including adding and deleting users,
All of the following:
and resetting passwords. Email should
1. Testing is administered and interpreted
be addressed to
by a licensed psychologist or other
prwebpass@ndbh.com.
qualified mental health provider (as
• Include the facility Tax ID
defined by applicable State and
• Indicate individual users first name, last
Federal law and scope of practice).
name and email address
Technician administered and/or
• Once New Directions receives and
computer assisted testing may be
processes the request, we will send an
allowed under the direct supervision of
email to each user. It will include a
a licensed psychologist or other
username and instructions on how to
qualified mental health provider.
complete the set up process.
Neuropsychological testing must be
Getting Started in WebPass supervised and interpreted by a
• The first time you log in to WebPass, licensed psychologist with
enter your username. You will be specialization in neuropsychology.
prompted to review the Terms of Use. 2. The requested tests must be
After you click "Agreed," you will standardized and have nationally
receive a second email that contains accepted validity and reliability.
your individual password. 3. The requested tests must have
normative data and suitability for use
with the patient's age group, culture,
Contains Public Information 16
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
primary language and developmental implementation of an individualized
level. treatment plan.
4. The requested time for administration,
Court-Ordered Admissions/Services
scoring and interpretation of the
BCBSKS consider court-ordered
proposed testing battery must be
admissions/services eligible if medical
consistent with the time requirements
necessity is met. These services are also
indicated by the test publisher.
subject to the member's individual
Service Request Criteria contract limitations. The court order does
Must meet all of the following: not negate the prior authorizations
1. An initial face-to-face complete requirements.
diagnostic assessment has been
Providers must obtain a waiver on any
completed.
mental health consultation, testing, or
2. The purpose of the proposed testing is
evaluation that is performed by agreement
to answer specific question(s)
or at the direction of a court for the
(identified in the initial diagnostic
purpose (i.e. assessing custody, visitation,
assessment) that cannot otherwise be
parental rights, determining damages of
answered by one or more
any kind of personal injury action), if the
comprehensive evaluations or
service is not otherwise medically
consultations with the patient,
necessary. In these cases, a GA modifier
family/support system, and other
should be added to the service on the
treating providers review of available
claim submission to indicate a valid waiver
records.
of liability has been signed by the patient.
3. The proposed battery of tests is
individualized to meet the patient’s
VIII. Diagnoses
needs and answer the specific
diagnostic/clinical questions identified ICD-10-CM Diagnoses
above. BCBSKS requires the use of the ICD-10-
4. The patient is cognitively able to CM coding system or the equivalence in
participate appropriately in the selected the DSM-V coding system.
battery of tests.
Comparison of DSM-V and ICD-10-CM
5. The results of the proposed testing can
According to the fifth edition DSM-V
reasonably be expected to contribute
manual (2013), "the primary purpose of
significantly in the development and
DSM-V is to assist trained clinicians in the
17 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
diagnosis of their patients' mental 5. Crosswalks will not include all of the
disorders as part of a case formulation coding notes. For example, instructions
assessment that leads to a fully informed regarding additional codes that should
treatment plan for each individual." The be included, which code should be
DSM-V was developed primarily by coded first and codes that should not
psychiatrists and produced and approved be coded together.
by the American Psychiatric Association.
Tobacco Disorder
There are many similarities between ICD-10-CM codes are for nicotine
DSM-V and ICD-10-CM, but there are dependence are in the F17 expanded
also significant differences. Some of the code range, and Z72.0 – for Tobacco use.
differences between the two include the
Tobacco use disorder is processed as an
following:
eligible psychiatric benefit when
1. Code descriptions in DSM-V may differ
performed by an eligible provider of
from the same ICD code description in
service.
ICD-10-CM.
2. Not all codes in ICD-10-CM, chapter Attention Deficit Disorder
five (Mental, Behavioral, and There is not a definitive test for Attention
Neurodevelopmental Disorders) are Deficit Disorder (ADD). If testing is done
included in DSM-V. for ADD, the provider should be specific
3. The diagnosis for Asperger's Disorder on the name of test, lab work and/or
has been removed from DSM-V and is testing being completed, so benefits can
now in the Autism Spectrum Disorder be determined. If actual services being
(F84.0) category; ICD-10-CM lists provided are known (i.e., psych testing,
Asperger's Disorder as a separate lab work, counseling), benefits can be
diagnosis (F84.5). quoted.
4. Crosswalks will not necessarily provide
Eye Movement Desensitization
an accurate ICD-10-CM code as there
and Reprocessing (EMDR)
are a number of "one to many"
Please refer to the Eye Movement
relationships. When comparing the
Desensitization and Reprocessing
code listed in DSM-V with a
(EMDR) for Acute Stress Disorder and
corresponding code in ICD-10-CM,
Post Traumatic Stress Disorder (PTSD)
there may be multiple options.
medical policy at bcbsks.com.
Contains Public Information 18
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
IX. Outpatient Coverage for Mental the American Psychiatric Association but
Conditions exclusive of those shown as "not
The conditions described in the member's attributable to a mental disorder that are a
basic coverage also control this section, focus of attention or treatment."
except where this section specifically
Limitations
states there is a change.
All of the limitations and the exclusions of
The Outpatient Services for Mental the Member's basic Contract or Certificate
Conditions section of the member's apply to the Rider, except for benefits
contract provides for the following specifically added by the Rider.
information in regard to Definitions,
Exclusions
Covered Providers, Covered Services and
The following exclusions apply only to
Limitations and Exclusions.
Outpatient Coverage for Mental
Definitions of Terms Conditions. All other general exclusions
Medical Care Facility – Any of the as described in the member's contract
following facilities that are licensed by the also apply.
State of Kansas to provide outpatient 1. Services received while the patient is
diagnosis and/or treatment of a Mental an inpatient in a Hospital or Medical
Condition: Care Facility.
• A psychiatric hospital 2. Non-medical services. This includes
• A community mental health center (but not limited to) legal services, social
Note – Facilities must operate within rehabilitation, educational services,
the scopes of their state licensure. vocational rehabilitation, and job
Note – If a facility also meets the placement services.
definition of "Hospital," it will be 3. Services of volunteers.
considered a Hospital and not a 4. Coverage for evaluations and
Medical Care Facility. Outpatient diagnostic tests ordered or requested in
services rendered by a hospital and connection with criminal actions,
submitted as "professional services" divorce, and child custody or child
are payable under the Outpatient visitation proceedings.
Nervous and Mental Rider.
Mental Condition – A disorder specified
in the Diagnostic and Statistical Manual of
19 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
X. Behavioral Health Intensive Treatment may appropriately be used to
Outpatient Program (IOP) transition persons from higher levels of
Intensive Outpatient care or may be provided for persons at
Psychotherapy – Adult risk of being admitted to higher levels of
Intensive Outpatient Psychotherapy (IOP) care. The goals, frequency, and duration
can be a freestanding or hospital-based of outpatient treatment will vary according
program. IOP services provide group to individual needs and response to
based, non-residential, intensive, treatment.
structured interventions consisting
Overall treatment is provided along a
primarily of counseling and education to
continuum of care placing patient at the
improve symptoms that may significantly
level that is clinically and medically
interfere with functioning in at least one
necessary. Patients can participate in only
life domain (e.g., familial,
one level of care at a time. When in IOP,
social/interpersonal, occupational,
services cannot be unbundled.
educational, health/medical compliance,
etc.). Requirements
The following are Behavioral Health IOP
Services are goal-oriented interactions
program requirements:
with the individual or in group/family
1. The facility/agency is licensed by the
settings. This community-based service
appropriate agency to provide IOP
allows the individual to apply skills in “real
treatment.
world” environments. Such treatment may
2. All direct service staff have the
be offered during the day, before or after
appropriate training and license to
work or school, in the evening or on a
provide IOP. Services provided by
weekend. The services follow a defined
volunteers, interns, trainees, etc., are
set of policies and procedures and clinical
not reimbursable.
protocols.
3. The program provides a minimum of
The service also provides a coordinated nine hours of direct services per week.
set of individualized treatment services to Typically, this is a minimum of three
persons who are able to function in a hours per day, three days per week.
school, work, and home environment but Direct services are face to face
are in need of treatment services beyond interactive services spent with licensed
traditional outpatient programs. staff. This does not include watching
films or videos, doing assigned
Contains Public Information 20
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
readings, doing assignments or filling psychopharmacology needs should be
out inventories or questionnaires, or part of the program and is the
participating in community based provider’s responsibility to coordinate
support groups. with other treating professionals.
4. During the first week of treatment 6. Twenty-four hours/seven days a week
patients must receive: (24/7) access to psychiatric and
a. A thorough, current, comprehensive psychological services must be
bio-psychosocial assessment. The available, either in house or by a
initial diagnostic interview must be referral relationship. Coordination
conducted by a physician between the mental health provider and
(psychiatrist preferred), Licensed other community provider is required.
Clinical Psychologist, (LCP) a. An Individualized treatment/recovery
Licensed Specialist Clinical Social plan, including discharge,
Worker, (LSCSW) or Advanced safety/crisis plan should be
Practice Registered Nurse (APRN) developed with the individual within
within the first week of treatment. the first week. Treatment planning
ICD-10-CM diagnosis is the primary must be individualized and address
focus of active treatment each the needs identified in the
program day. Assessments and assessment. Treatment goals should
treatment should address mental be set that are specific to the
health needs, and potentially, other individual, measureable, attainable,
co-occurring disorders. Physician relevant and time-focused.
evaluations must be available as Treatment plans should be modified
clinically indicated, but no less than to address any lack of treatment
once per week. progress. Treatment contracts are
b. Appropriate lab work should be strongly encouraged. This plan
obtained such as urine drug screens should be signed by all team
when appropriate (UDS) and Fasting members including the individual
Blood Glucose (FBG) levels for (the plan should consider community
patients on antipsychotic resources, family, current mental
medications and other lab work if health providers, primary care
medically indicated. providers and other supports).
5. Consultation and/or referral for general These plans should be reviewed on
medical, psychiatric, and an ongoing basis and adjusted as
21 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
medically indicated. Coordination of completed in person or
care with other providers is essential telephonically.
to quality treatment planning and 8. The agency must have written policies
successful discharge planning. and procedures related to their
b. Discharge planning should begin at program. Examples include:
day of admission and include • Admission and discharge criteria
coordination of care with current • Attendance expectations
therapist, family, and follow up • Use of illegal substances (positive
services/resources in the patient's UDS)
home community. Discharge follow • 24/7 availability to medical services
up appointments should be • Maintaining current licensure for
scheduled early in the program to providers
ensure the availability of resources • Reporting of critical incidents
within seven days of discharge. • Group size
7. Group, individual, and family therapies
must be available to the patient and Credentialing
used whenever clinically appropriate. The following information will need to be
The primary modality of IOP is group submitted for consideration:
therapy, but must include at least one 1. Copy of license to provide IOP
hour of individual therapy a week with treatment
an appropriately licensed provider. This 2. List of current staff providing direct care
is included in the IOP rate of care. in the facility, their credentials and
Members can participate in only one licensure
level of care at a time. 3. Facilities admission criteria
a. Psycho-educational components will 4. Facilities discharge criteria
be utilized as appropriate to the 5. Does the facility have adolescent-
individual’s needs. specific criteria?
b. If family treatment is documented as 6. Facility policy for how soon the
a clinical need, clear documentation individualized treatment plan and goals
and early involvement is expected. are set with the patient
Family meetings should occur in 7. List of all groups and treatment
person whenever possible. Clear program schedule
documentation as to level of family 8. Hours and days of service options. (i.e.
involvement and whether this was three days a week for three hours a
Contains Public Information 22
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
day may look like M-W-F schedule 9 providers, primary care physicians or
a.m.- noon). Please provide all options other medication managers if
available. indicated? Are community resources
9. For each group/session; what modalities provided?
are utilized? Keeping in mind that these 15. What is the facility policy regarding the
must be direct services. (Direct services development of a safety/crisis plan?
are face to face interactive services 16. What is the facility policy regarding
spent with licensed staff. Time spent group size?
watching films or videos, doing assigned 17. What is the facility policy of reporting
readings, doing assignments or filling critical/sentinel events?
out inventories or questionnaires, or
Coding
participating in community based
S9480 – Intensive outpatient psychiatric
support groups such as anxiety support,
services, per diem.
depression bipolar support and
• Any provider wanting to bill this
Breakthrough House are NOT
procedure code must have their
BILLABLE for treatment hours and
protocols reviewed to establish actual
cannot count towards the program
level of care that is being provided.
hours.)
Approved providers will be given
10. Outline of the availability to 24/7 psychiatric
permission to bill this code, and
and psychological services. If services are
guidelines to follow.
provided in house, provide the list of
• This is a per diem code, and includes
providers. If this is a contracted/referral
service, who is this service with? How do the following services: coordination of
care, individual/group/family
patients access this?
psychotherapy, evaluation and
11. What is the facility policy and
management service in the clinic
availability of obtaining UDS and
setting and pharmacologic
breathalyzers? Can these be done in
management. These services should
house or as a referral basis?
not be billed in addition to code S9480.
12. What is the facility attendance policy?
13. What is the facility policy regarding • Contact your Professional Relations
family involvement in treatment or why representative for further information.
it would not occur? • For IOP Programs – codes H0015 and
14. When is discharge planning initiated? S9480 are not allowed to be billed
Is care coordinated with out-patient together.
23 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
XI. AMA CPT Evaluation & • You CANNOT use time alone as the
Management Codes, Psychiatric method of code selection when
Codes & Guidelines psychotherapy is provided for the
In this section, you will find the more patient on the same day.
widely utilized CPT psychiatric codes and • Do not use modifier 25 in conjunction
subsequent BCBSKS billing guidelines. with your E&M code.
For procedural nomenclature, please refer • All E&M services must meet the
to your American Medical Association required components as outlined in the
CPT Reference. BCBSKS will be following CPT book.
guidelines as outlined in the CPT book,
with one exception: The patient must be Office or Other Outpatient Services
present in order to bill any service to Must be supported by documentation.
BCBSKS. Selecting the Appropriate E&M Code
Evaluation and Management (E&M) Three components:
BCBSKS allows Evaluation & • History
Management (E&M) services when billed • Exam
according to scope of practice provisions. • Medical decision-making
Provider types that may not bill E&M These components are KEY in selecting
services include (but are not limited to): the level of service.
• Licensed Clinical Social Workers
Patient Status
• Licensed Clinical Marriage and Family
• New patient codes (99201-99205)
Therapists
require all three key components (e.g.,
• Licensed Clinical Psychotherapists 99201 includes problem-focused
• Licensed Clinical Professional history, problem-focused exam, and
Counselors straight-forward medical decision-
• PhDs making.
These providers should bill the • Established patient codes (99211-
appropriate psychotherapy service codes 99215) require only two of the three
(90832-90853). components (e.g., 99212 would only
Billing for an E&M code and require problem-focused history and/or
psychotherapy services on the same day: exam and straight-forward medical
decision-making).
• The services must be significant and
separately identifiable.
Contains Public Information 24
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
• A patient is considered “NEW” when • Expanded problem-focused is
they have not been seen by the billing comprised of chief complaint, brief
provider within the past three years. history of present illness, problem
pertinent system review.
Counseling
• Detailed is comprised of chief
and/or Coordination of Care
complaint, extended history of present
• Counseling, coordination of care, and
illness, problem pertinent system
nature of presenting problem are
review extended to include a review of
considered contributory factors in the
a limited number of additional systems
majority of encounters.
(e.g., pertinent past, family and/or
• When counseling and/or coordination
social history directly related to the
of care dominates “more than 50
patient’s problem).
percent” of the encounter with patient
• Comprehensive is comprised of chief
or family, then TIME (as stated within
complaint; extended history of present
each code description) shall be the key
illness, review of systems that is
determining factor for the appropriate
directly related to problem(s) identified
selection of the E&M.
in the history of the present illness plus
• If performing “counseling and/or
a review of all additional body systems,
coordination of care,” your record
complete past, family, and social
should include:
history.
o Reference to start/stop times or total
time for the entire encounter; Examination
o Time spent counseling; and • Problem-focused is comprised of a
o Description of the counseling and/or limited examination of the affected
activities to coordinate care. body area or organ system.
• DO NOT include time spent performing • Expanded problem-focused is
psychotherapy as part of the comprised of a limited examination of
counseling time. the affected body area or organ system
and other symptomatic or related organ
Elements
system(s).
History
• Detailed is comprised of an extended
• Problem-focused is comprised of chief
examination of the affected body
complaint and brief history of present
area(s) and other symptomatic or
illness or problem.
related organ system(s).
25 Current Procedural Terminology © 2018 American Medical Association
All Rights Reserved.BEHAVIORAL HEALTH – Guidelines
• Comprehensive is comprised of a thoughts (e.g., logical vs. illogical,
general examination or a complete tangential, circumstantial, intact).
examination of a single organ system. • Description of abnormal or psychotic
thoughts, including hallucinations,
Psychiatric Examination
delusions, preoccupation with violence,
Constitutional – Measurement of any
homicidal or suicidal ideation, and
three of the following eight vital signs:
obsessions.
• Sitting or standing blood pressure
• Description of the patient’s judgment
• Supine blood pressure
(e.g., concerning everyday activities
• Pulse rate and regularity and social situation) and insight (e.g.,
• Respiration concerning psychiatric condition).
• Temperature • Complete mental status examination,
• Height including:
• Weight (may be measured and o Orientation to time, place and person
recorded by ancillary staff) o Recent and remote memory
• General appearance of a patient (e.g., o Attention span and concentration
development, nutrition, body habitus, o Language (e.g., naming object,
deformities, attention to grooming) repeating phrases)
o Fund of knowledge (e.g., awareness
Musculoskeletal
of current events, past history,
• Assessment of muscle strength and
vocabulary)
tone (e.g., flaccid, cog wheel, spastic)
o Mood and affect (e.g., depression,
with notation of any atrophy and
anxiety, agitation, hypomania, liability)
abnormal movements.
• Examination of gait and station. Medical Decision-Making
• Medical decision-making refers to the
Psychiatric
complexity of establishing a diagnosis
• Description of speech, including rate,
and/or selecting a management option.
volume, articulation, coherence, and
• The four types of medical decision-
spontaneity with notation of
making are recognized as:
abnormalities (e.g., perseveration,
o Straight-forward
paucity of language).
o Low complexity
• Description of thought processes,
o Moderate complexity
including rate of thoughts, content of
o High complexity
Contains Public Information 26
Revision Date: January 2019BEHAVIORAL HEALTH – Guidelines
Refer to complexity of medical the patient’s presenting problem and
decision-making table within CPT for documentation meets criteria for a
more information. 99212 level E&M code. In addition to
time spent on the E&M portion of the
E&M Coding Vignettes
visit, 20 minutes is spent providing
The following coding vignettes were
psychotherapy services.
provided by the American Academy of
o Both 99212 and 90833 (30 minutes
Child and Adolescent Psychiatry.
psychotherapy add-on) are reported.
Reporting of Time/Units for Psychiatric • Note – Codes 90833, 90836, and
Services: 90838 are add on codes and require a
• Psychotherapy must be 16 minutes or primary Evaluation and Management
more to be billable. code be billed.
• Time associated with activities used to
meet criteria for an E&M service is not XII. Coding
to be included in the time used for The following codes for treatment are for
reporting the psychotherapy service informational purposes.
(history, physical, etc.).
90785 – Interactive Complexity
• Time (counseling and coordination of
care) must be face-to-face between the This is an add-on code; bill in conjunction
provider and patient. with codes for diagnostic psychiatric
evaluation (90791, 90792), psychotherapy
A unit of time is attained when the (90832, 90834, 90837) psychotherapy
midpoint is passed. when performed with an evaluation and
o 16-37 minutes bill 30 minutes management service (90833, 90836,
o 38-52 minutes bill 45 minutes 90838, 99201-99255, 99304-99337,
o 53 or > minutes bill 60 minutes 99341-99350), and group psychotherapy
(90853).
Examples:
• Patient is seen for 40 minutes in the 90791-90792 – Psychiatric
office for psychotherapy. Diagnostic Evaluation
o Use code 90834 (45 minutes of • When 90791 or 90792 are billed with
psychotherapy). another psychiatric service, they will be
• Patient is seen in the office for an E&M denied content of the other psychiatric
visit with psychotherapy. The nature of service.
27 Current Procedural Terminology © 2018 American Medical Association
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