Professional Provider Manual - Behavioral Health

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Behavioral HealthBehavioral Healthbcbsks.comAn independent licensee of the Blue Cross Blue Shield Association.

BEHAVIORAL HEALTH – Table of ContentsTable of ContentsI.Eligible Providers and Facilities . 4II.Benefits . 4III.Documentation Guidelines. 5IV.Limited Patient Waiver . 10V.Medical Necessity . 11VI.Utilization Management . 12VII.BCBSKS/ NDBH Authorization Process . 14VIII.Diagnoses . 18IX.Outpatient Coverage for Mental Conditions . 20X.Behavioral Health Intensive Outpatient Program (IOP) . 21XI.AMA CPT Evaluation & Management Codes, Psychiatric Codes & Guidelines . 24XII.Coding. 29XIII.Telemedicine Services. 34Revisions . 36Contains Public InformationRevision Date: January 20212

BEHAVIORAL HEALTH – GuidelinesThis appendix to the Professional Provider Manual briefly describes the mental health benefitsand guidelines available to the members of Blue Cross and Blue Shield of Kansas. Theinformation applies specifically to those providing mental health services, on an inpatient andoutpatient basis.Acknowledgement – Current Procedural Terminology (CPT ) is copyright 2020 AmericanMedical Association (AMA). All Rights Reserved. No fee schedules, basic units, relativevalues or related listings are included in CPT. The AMA assumes no liability for the datacontained herein. Applicable – ARS/DFARS Restrictions Apply to Government UseNOTE – The revision date appears in the footer of the document. Links within the documentare updated as changes occur throughout the year.3Current Procedural Terminology 2020 American Medical AssociationAll Rights Reserved.

BEHAVIORAL HEALTH – GuidelinesI. Eligible Providers and FacilitiesBlue Cross and Blue Shield of Kansas (BCBSKS) reimburses outpatient mental healthservices provided by the following types of providers and facilities, as recognized by themember's contract. Providers who are unlicensed or who are not included among the coveredproviders listed below will not be reimbursed for psychotherapy or any other servicesconnected with a mental health diagnosis. Supervision of an unlicensed provider or a providernot listed below does not constitute a service being rendered by an eligible provider.1. Licensed Doctor of Medicine, or Doctor of Osteopathy2. Clinical Psychologist (PhD or PsyD) licensed to practice under the laws of the State ofKansas3. Licensed Social Worker authorized to engage in private independent practice (LSCSW)under the laws of the State of Kansas4. Licensed Clinical Marriage and Family Therapist (LCMFT)5. Licensed Clinical Professional Counselor (LCPC)6. Licensed Clinical Psychotherapist (LCP)7. Licensed Marriage and Family Therapist8. Licensed Master Level Psychologist9. Licensed Master Level Social Worker10. Licensed Master Addiction Counselor11. Licensed Professional Counselor12. Advanced Practice Registered Nurse (APRN), with a minimum of a master's degree inpsychiatric/mental health nursing or related mental health field13. Autism Specialist (AS)14. Intensive Individual Support Provider (IIS)15. Hospital16. State-licensed Medical Care Facility, defined as:a. A psychiatric hospitalb. A community mental health centerII. BenefitsFor member eligibility and benefit verification can be found on Availity at Availity.com.Contains Public InformationRevision Date: January 20214

BEHAVIORAL HEALTH – GuidelinesThrough Availity, providers can access both the Availity web portal and BlueAccess –BCBSKS's secure web portal – to view secure BCBSKS member claims and eligibilityinformation.The BCBSKS Provider Benefit Hotline in Topeka can be reached at 785-291-4183 or 800432-0272.III. Documentation GuidelinesThe importance of having the services performed sufficiently documented cannot be overemphasized.The following medical record standards are minimally required, and if not met, may result in aclaim denial and accordingly a provider write-off.Records must:1. Be legible in both readability and content. If not readable, reimbursement will be denied.2. Contain only those terms and abbreviations easily comprehended by peers of similarlicensure. If a legend is needed to review your records, please submit it with your records. Ifneeded and you have not submitted one, Blue Cross Blue Shield of Kansas may requestyou provide a legend. If not supplied upon request reimbursement will be denied.3. Contain personal/biographical information in a consistent location including the following: Name (first and last) – should be reflected on every page DOB (date of birth) – should be reflected on every page Home Address Home/work telephone numbers Employer or school name Marital or legal status Medication allergies with reactions Appropriate consent forms/guardianship information Emergency contact information4. Contain pertinent and significant information concerning the patient's presenting condition.This should include: Documentation of at least one mental health status evaluation (e.g. patient's affect,speech, mood, thought content, judgment, insight, attention or concentration, memory,and impulse control).5Current Procedural Terminology 2020 American Medical AssociationAll Rights Reserved.

BEHAVIORAL HEALTH – Guidelines Documentation of past and present use of tobacco, alcohol and prescribed, illicit, andover the counter drugs, including frequency and quantity. Psychiatric history which includes:o Previous treatment dateso Therapeutic interventions and responseso Sources of clinical data (e.g., self, mother, spouse, past medical records)o Relevant family informationo Consultation reports including psychological and neuropsychological testing (ifavailable/applicable)o Laboratory test results if applicable in physician and nurse practitioner records Medication management including medication prescribed; quantity or documentation ofno medication; and over the counter medication. For physician and nurse practitioners,this should also include the dosages and usage instructions of each medication and thedates of initial prescription and/or refills.5. Indicate the initial diagnosis and the patient's initial reason for seeking the provider's care.The diagnosis is not just an /ICD-10-CM billing code, but a written interpretation of thepatient's condition and physical findings. The diagnosis should be recorded in the recordand reflected on the claim form.6. Document the treatment provided. This would include the dates any professional servicewas provided. List start and stop times or total time on all timed codes per CPTnomenclature. If dates of services and/or start/stop (or reference to total time) are notrecorded, reimbursement may be reduced. Group documentation must indicate eachspecific encounter for the date of service and each session attended not a collectivesummary for multiple sessions or dates of service. Documentation should include durationand purpose of the group and medically necessity as indicated by the patient's individualtreatment plan.7. Treatment Plan: The treatment plan contains specific measurable goals, documentation ofthe treatment plan and/or goals discussed with the patient, estimated time frames for goalachievement, and documentation of the patient's strengths and limitations in achieving thegoals. The treatment plan should be individualized for each patient. Document the patient'sprogress during the course of treatment as it relates to the plan of care and diagnosis.Continuity and coordination of care should be reflected in the medical record, includingcommunication with or review of information from other behavioral health professional,Contains Public InformationRevision Date: January 20216

BEHAVIORAL HEALTH – Guidelinesancillary providers, primary care providers, and health care institutions. Referrals tocommunity outreach services and higher levels of care should be documented.8. Medical records of minor patients (under age 18) should contain documentation of prenataland parental events, along with complete developmental histories and evidence of familyinvolvement. Parental informed consent for all prescribed medications should be included.9. Signature Requirements — In the content of health records, each entry must beauthenticated by the author. Authentication is the process of providing proof of theauthorship signifying knowledge, approval, acceptance or obligation of the documentationin the health record, whether maintained in a paper or electronic format accomplished witha handwritten or electronic signature. Individuals providing care for the patient areresponsible for documentation of the care. The documentation must reflect who performedthe service.a. The handwritten signature must be legible and contain at least the first initial and full lastname along with credentials and date. A typed or printed name must be accompanied bya handwritten signature or initials with credentials and date.b. An electronic signature is a unique personal identifier such as a unique code,biometric, or password entered by the author of the electronic medical record (EMR) orelectronic health record (EHR) via electronic means, and is automatically andpermanently attached to the document when created including the author's first and lastname, with credentials, with automatic dating and time stamping of the entry. After theentry is electronically signed, the text-editing feature should not be available foramending documentation. Example of an electronically signed signature:"Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX A.M.c. A digital signature is a digitized version of a handwritten signature on a pen pad andautomatically converted to a digital signature that is affixed to the electronic document.The digital signature must be legible and contain the first and last name, credentials, anddate.d. Rubber stamp signatures are not permissible. This provision does not affect stampedsignatures on claims, which remain permissible.Documentation ErrorsListed below are a few documentation errors that are commonly missed. Start and stop times or duration7Current Procedural Terminology 2020 American Medical AssociationAll Rights Reserved.

BEHAVIORAL HEALTH – Guidelineso Not listing start and stop times or duration – Most CPT codes are time sensitive. It is goodpractice to document the face-to-face time and/or duration you spend with the patient. Treatment planningo Indicate if you made changes to the treatment plan goals or if the goals remainunchanged. Follow up appointmentso It is important to indicate when the next appointment is and, as appropriate, anydischarge planning. Patient's presentationo Reflect the patient's presentation in each face‐to‐face encounter note. This shouldcontain objective and subjective documentation of the patient’s presentation. Diagnosiso Be precise. Update as appropriate. Documentationo Documentation must match the requirements of the CPT code. Please refer to the mostcurrent CPT code book for specific requirements. Also, at www.ndbh.com provider tab,there is documentation on how to determine what codes are most appropriate.SOAP Note FormatIt is essential for the provider to document clinical notes and findings to support medicalnecessity. A format that may be used is a SOAP note. SOAP stands for Subjective, Objective,Assessment, and Plan.Subjective notes should reflect the following: Patient's reason for seeking care Duration of complaint Past medical history and treatment history Social history, tobacco use, alcohol use, substance abuse, illicit drug useObjective notes should reflect the following: Visual observation Reports from other counselors/therapists Results of psychological tests and widely accepted scales to measure the effectiveness ofcare (i.e. Beck Depression Inventory, Hamilton Depression Rating Scale, etc.)Contains Public InformationRevision Date: January 20218

BEHAVIORAL HEALTH – Guidelines Quantifiable termsAssessment notes should include the following: Initial evaluation Short term goals Long term goals Overall progressPlan notes should include the following: Referrals Interventions Anticipated discharge or referral Recommendations Prognosis with regard to the treatment planDocumentation - Keeping it SeparateA big challenge for providers is keeping psychotherapy notes separate from progress notes.Providers often keep just one note that documents the session with their client.It is vital for providers to understand that psychotherapy notes need to be documented andstored separately from