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July 1, 2006
 
 
 
MEDICAID INFORMATION RELEASE 2006-15
 
TO:                 Psychosocial Rehabilitation Agencies, Mental Health Clinics, Developmental     Disability Agencies, School-Based Providers, Speech and Hearing Clinic (ISSH), Developmental Disability Centers, Waiver Vendors, Independent Supervising Registered Nurse (PCS)
 
FROM:           Leslie Clement, Deputy Administrator
 
SUBJECT:     EXCLUSIONS AND LIMITATIONS OF MEDICAID BASIC PLAN BENEFITS
 
As a part of Medicaid Modernization, Medicaid benefits are changed according to participants’ needs effective for dates of service beginning July 1, 2006. There are three new benefits plans: Medicaid Basic Plan Benefits, Medicaid Enhanced Plan Benefits and Medicare/Medicaid Coordinated Plan Benefits. This Information Release describes the exclusions and limitations in Medicaid Basic Plan Benefits.
 
Schools
The following services are excluded from Medicaid Basic Plan Benefits except when provided by a school district:
  • Psychosocial Rehabilitation
  • Intensive Behavioral Intervention
  • Personal Care Services
  • Developmental Therapy
 
All services that are presently school-based will continue to be offered under Medicaid Basic Plan Benefits with the same limitations that presently exist.
 
Other Medicaid Providers
The following services are excluded from Medicaid Basic Plan Benefits:
  • Partial Care
  • Service Coordination
  • Intermediate care facility services (ICF-MR)
  • Nursing Facility Services
  • Home and Community-Based  Waiver Services (A&D, TBI, DD, ISSH)
  • Hospice Care
 
 
All above listed services continue to be covered in Medicaid Enhanced Plan Benefits. Evaluation to determine eligibility for these services is available under Medicaid Basic Plan Benefits. The services in Medicaid Enhanced Plan Benefits include the full range of services covered by the Idaho Medicaid program.
 
For certain provider specialties, services under Medicaid Basic Plan are restricted to diagnostic and evaluation procedures. This restriction applies to the following provider specialties:
 
  • 015 - Speech and Hearing Clinic (ISSH)
  • 130 - Developmental Disability Centers (DDAs)
  • 131 - Rehab Mental Health Services
  • 141 – Waiver Vendors
  • 163 - Independent Supervising Registered Nurse (PCS)
  • 164 - Licensed Practical Nurse Independent (PDN)
  • 165 - Nursing Agency (PDN)
  • 168 - Registered Nurse Services Independent DD Waiver
  • 169 - Registered Nurse Services Agency DD Waiver
  • 176 - Mental Health Case Management
  • 177 - Personal Care Services Case Management
 
Please see Table 1 for the list of the procedure codes and descriptions of the limited procedures allowed for the above identified provider types in Medicaid Basic Plan Benefits.
 
Table 1. Procedure Codes, Select Provider Specialties, and Procedure Descriptions
Allowed in Medicaid Basic Plan Benefits for the Purposes of Diagnosis and Evaluation Only
Procedure Code
Provider Specialty
Procedure Description
H2000
130
Comprehensive multidisciplinary evaluation; Developmental therapy evaluation
T1023
015 130 131 163 164 165 166 168 169
Screen for individual participation in specific program, project or treatment protocol; PWC-determination presumptive eligibility
T1028
130
131
Social History & Evaluation: Assessment of home, physical and family environment, to determine suitability to meet patient’s medical needs.
H0031
131
176
Rehabilitation evaluation  (Mental health assessment by non-physician)
90801
130
131
Psychiatric Diagnostic Interview Examination: includes history, mental status and disposition; may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies
90802
130
131
Interactive psychiatric diagnostic interview examination; using play equipment, physical devices, language interpreter, or other mechanisms of communication; typically furnished to children
92506
 015 141 130
Medical evaluation speech language and/or hear pro
96101
130
131
Psychological testing (includes psycho diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g.,  MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.
96102
130
131
Psychological testing  includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g.,  MMPI, WAIS),with qualified healthcare professional interpretation and report,  administered by technician, per hour of technician time, face-to-face.
96103
130
131
Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified healthcare professional interpretation and report.
97001
130
Physical therapy evaluation
97003
130
Occupational therapy evaluation
G9002
177
PCS Assessment: Coordinated Care Fee
 
The existing service limitation of twelve (12) hours of diagnostic and evaluation services still applies.
 
Medicaid Basic Plan Benefit participants will be limited to twenty-six (26) separate outpatient mental health clinic services annually and ten (10) psychiatric inpatient hospital days annually.
 
Please see Table 2 below for the applicable procedure codes that count toward the twenty-six (26) mental health service limitation allowed in Medicaid Basic Plan Benefits and the applicable procedure descriptions.
 
Table 2. Procedure Codes and Procedure Descriptions of Mental Health Services included in the Twenty-Six Service Limitation of Medicaid Basic Plan Benefits
Procedure Code
Procedure Descriptions
 
90801
 
 
Psychiatric Diagnostic Interview Examination: includes history, mental status and disposition; may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies.
 
90802
 
Interactive psychiatric diagnostic interview examination; using play equipment, physical devices, language interpreter, or other mechanisms of communication; typically furnished to children
90804
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility.  Approximately 20 to 30 minutes face-to-face with the patient.
 
 
90806
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
90808
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately  75 to 80  minutes face-to-face with the patient
90810
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient.
90812
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient.
90814
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient.
90847
Family Psychotherapy (conjoint psychotherapy) (with patient present)
90853
Group Psychotherapy (other than of a multiple-family group)
90857
Interactive Group Psychotherapy
90862
Pharmacological Management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
T1028
Social History Evaluation : Individualized intake assessment based on participant’s needs
96101
Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g.,  MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.
96102
Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, WAIS), with qualified healthcare professional interpretation and report,  administered by technician, per hour of technician time, face-to-face.
96103
Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified healthcare professional interpretation and report.
 
Other codes previously reimbursed by Medicaid in mental health clinics will continue to be reimbursed when provided in mental health clinics but will not count toward the twenty-six (26) service limitation. Please refer to the Provider Handbook for a full list of the services available in mental health clinics.
 
 
Billing Instructions for Twenty-Six Mental Health Service Limitation
 
Dates of service on the detail are limited to a single day. If a provider sees the participant more than once on the same day, the provider must bill each procedure as a separate claim detail with the appropriate modifier, 76 or 77, for justification of duplication.  Each occurrence of a procedure code on a claim detail will be counted as one service toward the 26 mental health service limitation regardless of the number of units or date of service on the detail. This limitation is based on a calendar year.
 
To ensure claims are not denied due to eligibility or benefit plan issues, verify the participant’s eligibility and benefit plan on the actual date of service.
 
If you have any questions concerning the information contained in this release, please contact Pat Guidry, at (208) 364-1813.
 
Thank you for your continued participation in the Idaho Medicaid Program.
 
LMC/pg/sw