Day Treatment/Partial Hospitalization

H0035

www.dmas.virginia.gov 1

Department of Medical Assistance Services

Day Treatment/Partial Hospitalization

2013

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DisclaimerThese slides contain only highlights of the Virginia Medicaid Community Mental Health Rehabilitative Services Manual (CHMRS) and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations.

*Please refer to the manual, available on the DMAS website portal, for in-depth information on Community Mental Health Rehabilitative Services criteria. Providers are responsible for adhering to related state and federal regulations.

www.vita.virginia.govwww.dmas.virginia.gov 2


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Objectives of this Training Are:

• To define the criteria of Day Treatment/Partial Hospitalization

• To identify staff qualifications;• To clarify eligibility criteria;• To identify required activities;• To review criteria for discharge• To review limitations of the service; • To outline service units and reimbursement; and• To review service authorization requirements.



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Service Definition

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Day treatment/partial hospitalization services are time limited interventions that are more intensive than outpatient services and are required to stabilize an individual’s psychiatric condition.

The service is delivered when the individual is at risk of psychiatric hospitalization or is transitioning from a psychiatric hospitalization to the community.

These services are programs of two or more consecutive hours per day, which may be scheduled multiple times per week and are provided to groups of individuals in a non-residential setting.



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Licensing

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Day Treatment/Partial Hospitalization providers must have a Department of Behavioral Health and Developmental Services (DBHDS) license to provide Day Treatment Services.



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Staff Qualifications

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Licensed Mental Health Professional (LMHP) or LMHP Supervisee or Resident

Qualified Mental Health Professional-Adult (QMHP-A)

Qualified Mental Health Professional-Eligible (QMHP-E)

Qualified Mental Health Paraprofessional (QPP or QMHPP)

* Qualification requirements may be found in Chapter II of the CMHRS Manual



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Eligibility Criteria

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Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis:

a. Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness or isolation from social supports;



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b.Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;

c.Exhibit behavior that requires repeated interventions or monitoring by the mental health, social services, or judicial system; or

d.Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.



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If an individual has co-occurring mental health and substance use disorders, integrated treatment for both is allowed as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be clearly documented in the assessment, treatment plan and progress notes.



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Required Activities

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Services may be provided following a service-specific provider assessment completed by a Licensed Mental Health Professional (LMHP) and authorized by a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, or licensed clinical nurse specialist-psychiatric.

The service-specific provider assessment must be performed face-to-face by an LMHP.



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Within 30 days of service initiation, the Individual Service Plan (ISP) must be completed by an LMHP, LMHP Supervisee or Resident or the Qualified Mental Health Professional-Adult (QMHP-A) or QMHP-eligible (E).

Services must be provided in accordance with the ISP. Progress notes are completed when services are delivered.

The documentation must include: the date the service or activity was provided, the arrival and departure time of each individual to and from

the program, the amount of service delivered and a staff’s signature, credentials, and date.



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Services for time periods longer than 90 calendar days must be authorized based upon a face-to-face evaluation by a physician, psychiatrist, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker or psychiatric clinical nurse specialist.

The ISP must be rewritten at least annually.

The program must operate a minimum of two continuous hours in a 24-hour period.



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If case management is being provided, there must be coordination with the case management agency.

The service provider must notify or document the attempts to notify the primary care provider of the individual’s receipt of this service.

At a minimum services are provided by qualified paraprofessionals under the supervision of a QMHP-A, LMHP, or LMHP Resident/Supervisee.



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Discharge Criteria

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Individuals must be discharged from this service when they are no longer in an acute psychiatric state and other less intensive services may achieve psychiatric stabilization.

Medicaid reimbursement is not available when other less intensive services may achieve stabilization or if the following applies:

The individual is no longer in an acute psychiatric state and at risk of psychiatric hospitalization and;

The level of functioning has improved with respect to the goals outlined in the ISP, and the individual can reasonably be expected to maintain these gains at a lower level of treatment.



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Limitations and Supervision Requirements

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Paraprofessionals who do not meet the experience requirements listed in Chapter II of the Community Mental Health Rehabilitative Services (CMHRS) Manual may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and supervised by a QMHP-A.

Supervision must include: On-site observation of services Face-to-face consultation with the paraprofessional (this may

be group or individual) A review of the individual’s progress towards achieving ISP

goals and objectives and Recommendations for ISP changes based on the individual’s

status.www.vita.virginia.govwww.dmas.virginia.gov 22


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Supervision, either group or individual, must occur and be documented in the clinical record monthly and signed by the individual providing supervision.

Staff Travel time is excluded

Vocational services are not reimbursable



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Units and Reimbursement

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Day treatment/partial hospitalization(H0035) requires service authorization before any services (beyond the service-specific provider assessment) are reimbursed.

The service limit for service-specific provider assessments is 2 per provider per individual per fiscal year. This allows each provider to bill 2 service-specific provider assessments for each individual from July 1 – June 30 of every year.

The service-specific provider assessment code (H0032 with a U7 Modifier) must be billed before the service treatment (H0035) will pay in the Medicaid Management of Information System (MMIS) claims system.



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There is a maximum of 780 units that are allowed based on medical necessity per fiscal year. A claim edit is in place that will cut back payment or deny claims for services beyond the maximum number of units allowed.

One unit = 2 to 3.99 hours Two Units = 4 to 6.99 hours

Three Units = 7+ hours

No more than three units may be billed per day



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Each July 1st all service limits will be set to zero.

A fiscal year is July 1 through June 30.

Claims must be billed with an HB modifier. (Please note the special billing instructions included in Chapter V of the Community Mental Health Rehabilitative Services (CMHRS) Manual).



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Service Authorization

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KePRO is the DMAS contractor for Service Authorization (SA). For questions go to the SA website:

DMAS.KePRO.org and click on Virginia Medicaid

Phone: 1-888-VAPAUTH or 1-888-827-2884

Fax: 1-877-OKBYFAX or 1-877-652-9329

Web: [email protected]



mailto:[email protected]

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Submitting a request

The preferred method is through the Atrezzo® web-based program

Registration is required

Information on Atrezzo is available on the KePRO website, or call 1-888-827-2884 or (804) 622-8900 or mail to:

» KePro» 2810 North Parham Rd, Suite 305» Henrico, Virginia 23294



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Initial review is required to be submitted to the SA contractor at admission.

Continued stay reviews are required to be submitted to the SA contractor prior to, however not more than 30 days before, the end of the current approval.

Clinical information is needed from the provider for review for medical necessity criteria. A checklist for both the initial and continued stay review is located at dmas.kepro.org.



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Day Treatment/Partial HospitalizationRequests should include:

A DSM diagnosis (V codes are not acceptable as stand alone diagnosis).

If there is a dual diagnosis of mental health and substance abuse, services must be integrated

Describe symptoms/severity of illness Demonstrate clinical necessity for the services with specific

examples of how the individual meets each of the eligibility criteria.

** Use of the KePRO checklist helps to ensure that all required information is submitted and expedites review by reducing the need for requests to be pended for additional information.**



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Helpful Resources:

• 12VAC30-50-226 - Emergency Regulations for Community Mental Health Services

• Virginia Medicaid Web Portal link www.virginiamedicaid.dmas.virginia.gov

• DMAS Office of Behavioral Health:– Email Address [email protected]

• DMAS Helpline: 804-786-6273 Richmond Area1-800-552-8627 All other



http://www.virginiamedicaid.dmas.virginia.gov/

mailto:[email protected]

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Thank you for attending this training and helping to serve Virginia’s Medicaid Recipients.



Day Treatment/Partial Hospitalization

Documents

Transcript of Day Treatment/Partial Hospitalization