SECTION 13 - BENEFITS AND LIMITATIONS - MO HealthNet ...

Section 13 - Benefits and Limitations

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SECTION 13 - BENEFITS AND LIMITATIONS

13.1 AUTHORIZATION...................................................................................................................... 4

13.2 PROVIDER PARTICIPATION.................................................................................................. 4

13.3 RETENTION OF RECORDS ..................................................................................................... 5

13.4 ADEQUATE DOCUMENTATION............................................................................................ 6

13.5 NONDISCRIMINATION ............................................................................................................ 7

13.6 ELIGIBILITY............................................................................................................................... 7

13.7 PARTICIPANT COPAY.............................................................................................................. 8

13.8 PARTICIPANT NONLIABILITY.............................................................................................. 8

13.9 DEFINITIONS .............................................................................................................................. 8

13.9.A CPR PROVIDER .................................................................................................................... 8

13.9.B A QUALIFIED MENTAL HEALTH PROFESSIONAL ....................................................... 9

13.9.C SERIOUSLY MENTALLY ILL........................................................................................... 10

13.10 PLACE OF SERVICE................................................................................................................ 10

13.11 PRIOR CONTENTS NO LONGER APPLICABLE .............................................................. 10

13.12 GENERAL LIMITATIONS ...................................................................................................... 10

13.13 DELIVERY OF COMMUNITY PSYCHIATRIC REHABILITATION SERVICES......... 11

13.13.A PARTICIPANT ELIGIBILITY—INTAKE EVALUATION .............................................. 11

13.13.B EVALUATION TEAM ........................................................................................................ 12

13.13.C INTAKE EVALUATION..................................................................................................... 12

13.13.D TREATMENT PLANNING ................................................................................................. 12

13.13.E PERIODIC TREATMENT PLAN REVIEW ....................................................................... 12

13.13.F ANNUAL EVALUATION................................................................................................... 12

13.14 ADMISSION TO CPR ............................................................................................................... 12

13.14.A DIAGNOSIS......................................................................................................................... 13

13.14.B DISABILITY ........................................................................................................................ 13

13.14.C DURATION.......................................................................................................................... 13

13.14.D PROVISIONAL ADMISSION FOR CHILDREN AND ADOLESCENTS......................... 14

13.14.E ENROLLMENT ................................................................................................................... 15

Community Psychiatric Rehabilitation Program Manual

Last Updated - 06/29/2008Archived - 09##2013

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13.15 COVERED SERVICES.............................................................................................................. 15

13.15.A MODIFIERS......................................................................................................................... 15

13.15.B INTAKE EVALUATION..................................................................................................... 16

13.15.C ANNUAL EVALUATION................................................................................................... 16

13.15.D TREATMENT PLANNING ................................................................................................. 17

13.15.E BRIEF EVALUATION - QMHP.......................................................................................... 19

13.15.F LIMITATIONS (FOR BOTH INTAKE AND ANNUAL

EVALUATIONS/TREATMENT PLAN) ............................................................................................ 19

13.15.G DOCUMENTATION REQUIREMENTS (FOR BOTH INTAKE AND ANNUAL

EVALUATIONS\TREATMENT PLAN) ............................................................................................ 19

13.15.H CRISIS INTERVENTION AND RESOLUTION ................................................................ 19

13.15.H(1) Limitations .................................................................................................................... 20

13.15.H(2) Documentation Requirements....................................................................................... 20

13.15.I PRIOR CONTENTS NO LONGER APPLICABLE ............................................................ 21

13.15.J MEDICATION SERVICES ................................................................................................. 21

13.15.J(1) Documentation Requirements....................................................................................... 21

13.15.K MEDICATION ADMINISTRATION.................................................................................. 22

13.15.K(1) Limitations .................................................................................................................... 23

13.15.K(2) Documentation Requirements....................................................................................... 23

13.15.L INJECTABLE MEDICATIONS .......................................................................................... 23

13.15.L(1) Limitations .................................................................................................................... 23

13.15.L(2) Documentation Requirements....................................................................................... 24

13.15.M COMMUNITY SUPPORT ................................................................................................... 24

13.15.M(1) Limitations .................................................................................................................... 26

13.15.M(2) Documentation Requirements....................................................................................... 26

13.15.N INTENSIVE COMMUNITY PSYCHIATRIC REHABILITATION .................................. 26

13.15.N(1) Limitations .................................................................................................................... 29

13.15.O COMMUNITY SUPPORT ASSISTANT............................................................................. 29

13.15.O(1) Limitations .................................................................................................................... 30

13.15.P PSYCHOSOCIAL REHABILITATION.............................................................................. 30



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13.15.P(1) Limitations .................................................................................................................... 31

13.15.P(2) Documentation Requirements....................................................................................... 31

13.15.Q CONSULTATION SERVICES............................................................................................ 31

13.15.Q(1) Limitations .................................................................................................................... 32

13.15.R CO-OCCURRING SERVICES ............................................................................................ 32

13.15.R(1) Co-Occurring Individual Counseling............................................................................ 32

13.15.R(2) Co-Occurring Group Counseling.................................................................................. 33

13.15.R(3) Co-Occurring Group Education.................................................................................... 33

13.15.R(4) Co-Occurring Assessment Supplement ........................................................................ 34

13.15.S ORGANIZED HEALTH CARE DELIVERY SYSTEM (OHCDS)..................................... 34

13.16 LABORATORY SERVICES..................................................................................................... 35

13.17 PRESCRIPTION DRUGS ......................................................................................................... 35

13.18 MANAGED HEALTH CARE PROGRAM............................................................................. 35

13.19 ADMINISTRATIVE LOCK-IN................................................................................................ 35

13.20 GENERAL RELIEF PARTICIPANTS (TEXT DEL. 3/08) .................................................... 35

13.21 DIAGNOSIS CODES ................................................................................................................. 35

13.22 QUALITY ASSURANCE .......................................................................................................... 35

13.23 PRIOR CONTENTS NO LONGER APPLICABLE .............................................................. 35

13.24 CARE MANAGEMENT ORGANIZATION........................................................................... 36



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SECTION 13-BENEFITS AND LIMITATIONS

Community Psychiatric Rehabilitation (CPR) Program coverage is targeted to certain seriously mentally ill MO HealthNet eligible participants. Services include assessment, treatment and community support services furnished by or under the supervision or recommendation of a physician. Reimbursement is limited to qualified MO HealthNet enrolled CPR providers. This program provides community based services designed to maximize independent functioning and promote community adjustment and integration. This section provides the general benefits and limitations for the program.

13.1 AUTHORIZATION

Section 208.152, RSMo authorizes coverage of CPR services when such services are provided by community mental health facilities that qualify as CPR providers in accordance with State Regulation 9 CSR 30-4.030 through 30-4.047 and 9 CSR 10-7.010 through 10-7.140.

13.2 PROVIDER PARTICIPATION

To participate in the MO HealthNet Program, the CPR provider must satisfy the following requirements:

• Be certified as a CPR provider by the Department of Mental Health (DMH) (State Regulation 9 CSR 30-4.030 through 30-4.047 and 9 CSR 10-7.010 through 10-7.140) and submit a copy of the current certification with the enrollment forms. In order to receive federal funds and participate in the MO HealthNet Program all providers must comply with all applicable civil rights laws and regulations in the delivery of services. It is the provider's responsibility to review the civil rights information via the Internet at www.dss.mo.gov/mhd.

• Complete a "MO HealthNet Division Title XIX Participation Agreement for Community Psychiatric Rehabilitation Services" and "MO HealthNet Provider Questionnaire;"

• Complete a "MO HealthNet Enrollment Application" form;

• Agree to maintain for five (5) years, or longer if specified by a contract with DMH, auditable program records reflecting services provided, participant progress, number and kinds of participants served and other relevant program records;

• Allow the Department of Social Services (DSS) or its authorized representative, (DMH), to inspect and examine its premises and records that relate to the provision of services under this program; and



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• Employ and retain qualified/licensed mental health professionals qualified to render the services covered through the MO HealthNet CPR Program.

Please review Section 2 for a further discussion of provider participation. Requests for participation in the program should be sent to the MO HealthNet Division, Provider Enrollment Unit, P.O. Box 6500, Jefferson City, MO 65102 or e-mail to [email protected].

The Department of Mental Health (DMH), through an inter-agency agreement with the Department of Social Services (DSS), MO HealthNet Division (MHD), reviews all requests for participation in CPR and provides validation of the applicant's certification status to MHD. MHD, based upon review of the application and certification by DMH, approves or denies the application request.

The Provider Enrollment Unit must be notified in writing of any changes in the CPR provider's status. The notification must include the provider number and the requested change. Examples of changes are: Address or telephone number change; change from a Social Security number to a Tax Payer I.D. number; change in certification status, etc.

Specific information about MO HealthNet participation requirements for CPR can be obtained from the Provider Enrollment Unit, MO HealthNet Division P.O. Box 6500, Jefferson City, Missouri 65102 or e-mail [email protected].

13.3 RETENTION OF RECORDS

MO HealthNet providers must retain for 5 years, from the date of service, fiscal and medical records that coincide with and fully document services billed to the MO HealthNet Agency, and must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal and retain adequate documentation for services billed to the MO HealthNet Program may result in recovery of the payments for those services not adequately documented and may result in sanctions to the provider's participation in the MO HealthNet Program. This policy continues to apply in the event of the provider's discontinuance as an actively participating MO HealthNet provider through change of ownership or any other circumstance.

Documents retained by CPR providers must include the treatment plan and the clinical records. Information must be sufficient to disclose the actual provider of the service, quantity, quality, appropriateness and timeliness of services provided under the agreement.

In addition, DMH has the authority to institute sanctions for lack of documentation of adequate performance of administrative and clinical responsibilities. DMH sanctions include, but are not limited to, suspension of certification, reinstatement of clinical review, suspension of new participant admission, decertification, or other actions as determined by DMH.



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13.4 ADEQUATE DOCUMENTATION

All services provided must be adequately documented in the medical record. The Code of State Regulations, 13 CSR 70-3.030(2)(A) 1-12 (as applicable) defines "adequate documentation" and "adequate medical records" as follows:

Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty.

Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnoses, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered. An adequate and complete patient record is a record which is legible, which is made contemporaneously with the delivery of the service, which addresses the patient specifics, which include, at a minimum, individualized statements that support the assessment or treatment encounter.

Documentation required for CPR MO HealthNet reimbursement of each session, service, or activity excluding psychosocial rehabilitation shall consist of the following:

• First name, and last name, and either middle initial or date of birth of the MO HealthNet participant;

• An accurate, complete, and legible description of each service(s) provided;

• Name, title, and signature of the MO HealthNet enrolled provider delivering the service. Services provided by an individual under the direction or supervision of a MO HealthNet provider are not reimbursed by MO HealthNet. Services provided by a person not enrolled with MO HealthNet are not reimbursed by MO HealthNet;

• The name of the referring entity, when applicable;

• The date of service (month/day/year);

• For those MO HealthNet programs and services that are reimbursed according to the amount of time spent in delivering or rendering a service(s), the actual begin and end time taken to deliver the service (for example, 4:00 - 4:30 p.m.);

• The setting in which the service was rendered;

• The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary.

• The need for the service(s) in relationship to the MO HealthNet participant's treatment plan; and



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• The MO HealthNet participant's progress toward the goals stated in the treatment plan (progress notes);

Documentation required in the clinical record for psychosocial rehabilitation contains:

• weekly notes that include a summary of the patient's participation, involvement in and response to the services received, and the relationship of the services to the treatment regiment described in the treatment plan; and

• pertinent information reported by family members, or significant others, regarding a change in the participant's condition and/or an unusual or unexpected occurrence in the participant's life.

• daily attendance records or logs that include actual attendance times, as well as activity or session attended.

All of the documentation requirements listed above represent minimal elements for record keeping; however, additional documentation may be needed to satisfy the requirements of outside reviewers.

A provider’s failure to furnish, reveal and retain adequate documentation for services billed to MO HealthNet can result in the recovery of the payments for those services not adequately documented and can result in sanctions to the provider’s participation in the MO HealthNet program. This policy continues to be applicable in the event the provider discontinues as an active participating MO HealthNet enrolled provider as the result of a change of ownership or any other circumstance.

13.5 NONDISCRIMINATION

Providers must comply with the 1964 Civil Rights Act, as amended; Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; the Omnibus Reconciliation Act of 1981 and the Americans with Disabilities Act of 1990 and all other applicable Federal and State Laws that prohibit discrimination in the delivery of services on the basis of race, color, national origin, age, sex, handicap/disability or religious beliefs.

Further, all parties agree to comply with Title VII of the Civil Rights Act of 1964 which prohibits discrimination in employment on the basis of race, color, national origin, age, sex, handicap/disability, and religious beliefs.

13.6 ELIGIBILITY

The participant must be eligible for MO HealthNet coverage on each date a service is rendered in order for reimbursement to be made to a provider.



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13.7 PARTICIPANT COPAY

Participants eligible to receive certain MO HealthNet services are required to pay a small portion of the cost of the services. This amount is referred to as copay. The copay amount is paid by the participant at the time services are rendered. Services of the Community Psychiatric Rehabilitation Program are not subject to a copay amount. The provider must accept in full the amounts paid by the state agency.

13.8 PARTICIPANT NONLIABILITY

MO HealthNet covered services rendered to an eligible participant are not billable to the participant if MO HealthNet would have paid had the provider followed the proper policies and procedures for obtaining payment through the MO HealthNet Program as set forth in 13 CSR 70-4.030.

13.9 DEFINITIONS

13.9.A CPR PROVIDER

By definition, a provider of CPR services is an entity that is certified by the Department of Mental Health (DMH) as set forth in state regulation 9 CSR 30-4.030 through 30-4.047 and 9 CSR 10-7.010 through 10-7.140. Certification is contingent upon the provision of the core services listed below. These services may be provided directly or by subcontract. The required service functions include the following:

• Intake evaluation

• Annual evaluation

• Treatment planning

• Crisis intervention and resolution

• Community Support

• Intensive community psychiatric rehabilitation

• Medication services

• Medication services, professional

• Medication administration

• Psychosocial rehabilitation

• Physician consultation



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13.9.B A QUALIFIED MENTAL HEALTH PROFESSIONAL

A qualified mental health professional (QMHP) for the purpose of administration of the MO HealthNet CPR, is defined as:

• a physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one year of experience, under supervision, in treating problems related to mental illness or specialized training.

• a psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH.

• a psychologist licensed under Missouri law to practice psychology with specialized training in mental health services.

• a professional counselor licensed under Missouri law to practice counseling with specialized training in mental health services.

• a clinical social worker with a master's degree in social work from an accredited program and with specialized training in mental health services.

• a psychiatric nurse licensed under Chapter 335 RSMo., as a registered professional nurse with at least two years of experience in a psychiatric or substance abuse treatment setting or a master's degree in psychiatric nursing.

• an individual possessing a master's or doctorate degree in counseling and guidance, vocational counseling, pastoral counseling, rehabilitation counseling or guidance, psychology, family therapy, or related field, who has successfully completed a practicum or has one year of experience under the supervision of a qualified mental health professional.

• an occupational therapist certified by the American Occupational Therapy Certification Board, registered in Missouri, who has a bachelor's degree and has completed a practicum in a psychiatric setting or has one year experience in a psychiatric setting or has a master's degree and has completed either a practicum in a psychiatric setting or has one year of experience in a psychiatric setting.

• an advanced practice nurse under Chapter 335.016 RSMo who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing.



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• a psychiatric pharmacist who is a registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board certified pharmacist (BCPP) through the Board of Pharmaceutical Specialties or a registered pharmacist currently in a psychopharmacy residency where the service has been supervised by a board certified psychiatric pharmacist.

13.9.C SERIOUSLY MENTALLY ILL

Persons with serious mental illness experience mental disorders that interfere with functional capacities in relation to such primary aspects of daily life as self-care, interpersonal relationships and work or schooling. These disorders may often necessitate prolonged mental health care.

The following conditions are not included in the definition of serious mental illness unless accompanied by one of the specific principal diagnoses of mental illness listed in Section 18 of this manual:

• Mental retardation, developmental disabilities, or narcolepsy;

• Simple intoxication caused by substance abuse such as alcohol or drugs;

• Dependence upon or addiction to any substance such as alcohol or drugs; and

• Any other disorders such as organic brain syndrome, which are not of an actively psychotic nature.

13.10 PLACE OF SERVICE

A CPR provider may provide care in the following places of service (POS):

11—Office

12—Home

99—Other Unlisted Facility

13.11 PRIOR CONTENTS NO LONGER APPLICABLE

13.12 GENERAL LIMITATIONS

The following general limitations apply to all services provided through CPR:

• The service must be medically necessary.

• The service must be rendered by or under the direction or recommendation of a physician who participates in and approves the treatment plan. A licensed psychologist may approve



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the treatment plan only when the participant is currently receiving no prescribed medications and the clinical recommendations do not include a need for prescribed medications. An advanced practice nurse may approve the treatment plan if that individual is providing medication management services to the participant.

• The service must be rendered by an appropriate and qualified individual or professional as defined in this manual and in State Regulation 9 CSR 30-4.030 through 30-4.047 and 9 CSR 10-7.010 through 10-7.140.

• The service must be reasonable to the treatment of an individual's specific mental illness or disorder.

• Only specified injectable psychotropic medications are covered through CPR. Other prescription drugs included on the MO HealthNet Formulary are covered through the MO HealthNet Pharmacy Program when dispensed by a MO HealthNet participating pharmacy provider.

• Services are restricted to treatments required for:

• rehabilitation of identified deficits in community living skills;

• the control of debilitating symptoms; and

• stabilization of acute episodes that create a risk of inpatient admission and/or deterioration of the participant's condition.

• All other payers, e.g. Medicare, Veterans Administration and third party insurance must be billed prior to billing MO HealthNet when applicable.

• Services are not covered for persons who are receiving psychiatric inpatient hospital treatment or who are residents of a MO HealthNet participating nursing facility.

• Services are not covered by MO HealthNet for individuals residing in a jail or detention facility.

13.13 DELIVERY OF COMMUNITY PSYCHIATRIC REHABILITATION SERVICES

13.13.A PARTICIPANT ELIGIBILITY—INTAKE EVALUATION

An intake evaluation must be performed for each participant considered for entry into CPR. This applies to any organized program or course of treatment that a participant enters or attends for the purpose of receiving scheduled or planned mental health treatment that is to be reimbursed under MO HealthNet CPR.



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The intake evaluation shall be the basis for determining the participant's program eligibility according to disability, diagnosis, duration and the need for mental health treatment.

For each participant, the written clinical record must include a recommendation by the evaluation team that community psychiatric rehabilitation services are appropriate to meet the participant's individual treatment needs.

13.13.B EVALUATION TEAM

The intake evaluation must be performed by an evaluation team that includes, at a minimum, a physician and one other QMHP experienced in the diagnosis and treatment of mental illness.

13.13.C INTAKE EVALUATION

The diagnosis, disability and duration determination shall be based on the findings of a psychosocial/clinical assessment as described in Section 13.15.B.

13.13.D TREATMENT PLANNING

The completion of an initial treatment plan is required for all participants. The treatment plan must include components required by DMH. The treatment plan shall be based on the participant's intake evaluation findings and contain those items specified in Section 13.15.D.

13.13.E PERIODIC TREATMENT PLAN REVIEW

A team, which is minimally composed of a QMHP and community support worker, if appropriate, shall review the participant's treatment plan, goals and objectives on a regular basis as determined by department policy. Refer to Section 13.15.D. The review determines the participant's progress toward the treatment objectives, the appropriateness of the services being furnished and the need for the participant's continued participation in specific community psychiatric rehabilitation services. The CPR provider shall ensure the patient participates in the treatment plan review and signs the treatment plan.

13.13.F ANNUAL EVALUATION

The evaluation team shall conduct an annual evaluation for each participant who continues to require treatment. The annual evaluation shall meet all the requirements described in Section 13.15.C. and must be completed within 30 days following the anniversary date of the participant's intake evaluation.

13.14 ADMISSION TO CPR



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The administrative agent and its approved designee are authorized by the Division of Comprehensive Psychiatric Services as entry and exit points into the state mental health service delivery system for a geographic service area defined by the Division of Comprehensive Psychiatric Services (9 CSR 30.4-030 A).

13.14.A DIAGNOSIS

Program eligibility is restricted to those participants who are MO HealthNet eligible and who have one of the specific diagnoses listed in Section 18. A physician or licensed psychologist shall certify a primary diagnosis as defined in 9 CSR 10-7.140(2)(OO) or International Classification of Diseases, Ninth Revision with Clinical Modification (ICD-9-CM), using the current edition of the manual. This diagnosis may coexist with other psychiatric diagnoses in Axis I or other areas. See Section 18 for common ICD-9-CM and DSM-IV diagnoses for CPR.

13.14.B DISABILITY

There shall be clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two areas of behavioral functioning, as indicated by intake evaluation and assessment.

• Social role functioning/family life—the ability to sustain functionally the role of a worker, student, homemaker, family member or a combination of these; and

• Daily living skills/self-care skills—the ability to engage in personal care (such as grooming, personal hygiene) and community living (handling personal finances, using community resources, performing household chores), learning ability/self-direction and activities appropriate to the individual's age, developmental level and social role functioning.

13.14.C DURATION

Rehabilitation services shall be provided to those individuals whose mental illness is of sufficient duration as evidenced by one or more of the following occurrences:

1. Persons who have undergone psychiatric treatment more intensive than outpatient more than once in a lifetime (crisis services, alternative home care, partial hospital, inpatient);

2. Persons who have experienced an episode of continuous residential care other than hospitalization, for a period long enough to disrupt the normal living situation;

3. Persons who have exhibited the psychiatric disability for one year or more; or



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4. Persons whose treatment of psychiatric disorders has been or will be required for longer than six months.

13.14.D PROVISIONAL ADMISSION FOR CHILDREN AND ADOLESCENTS

Under the following circumstances, children and adolescents under the age of 18 years of age may be provisionally admitted to Community Psychiatric Rehabilitation Program services:

• Disability: There shall be clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two areas of behavioral functioning as indicated by intake and assessment:

1. Social role functioning/family life—the individual is at risk-of-out of home or out-of-school placement; and

2. Daily living skills/self-care skills—the individual is unable to engage in personal care (such as grooming, personal hygiene) and community living (performing school work or household chores), learning, self-direction or activities appropriate to the individual's age, developmental level and social role functioning;

• Diagnosis: If a person is exhibiting behaviors or symptoms that are consistent with a non-established CPR eligible diagnosis, they may be provisionally admitted to CPR for further evaluation. There may be insufficient clinical information because of rapidly changing developmental needs to determine if a CPR diagnosis is appropriate without an opportunity to observe and evaluate the person's behavior, mood and functional status. In such cases, there must be documentation that clearly supports the individual's level of functioning as defined in 9 CSR 30-4.042 (5)(A) "Disability".

• Duration: There must be documented evidence of an individual's functional disability as defined in 9 CSR 30-4.042 (5)(A) "Disability" for a period of 90 days prior to provisional admission.

• Provisional admissions shall not exceed 90 days. Immediately upon completion of the 90 days or sooner, if the individual has been determined to have an eligible diagnosis as listed in 9 CSR 30-4.042 (4) (B) of the rule, the diagnosis must be documented and the individual may continue in the CPR Program.

• If an individual who has been provisionally admitted is determined to be ineligible for CPR services, staff shall directly assist the individual and/or family in arranging appropriate follow-up services. Follow-up services shall be documented in the discharge summary of the clinical record.



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• All admission documentation is required for those provisionally admitted, with the exception of the comprehensive evaluation which may be deferred for 90 days

To be eligible to serve children and youth under the age of 18 a certified community psychiatric rehabilitation (CPR) provider shall meet each of the following requirements:

• Have a current and valid purchase of service contract with the Division of Comprehensive Psychiatric Services;

• Must meet the eligibility requirements for receipt of federal mental health block grant funds;

• Must provide a comprehensive array of psychiatric services to children and youth including but not limited to:

1. Crisis intervention mobile response;

2. Screening and assessment;

3. Medication services; and

4. Intensive case management consistent with state plan approved services; and

• Have experience and expertise in delivering a division approved home-based crisis intervention program of psychiatric services for children and youth.

13.14.E ENROLLMENT

To be eligible for reimbursement of services, the provider must enroll the participant for CPR services by submitting required information to the DMH participant information system data base.

13.15 COVERED SERVICES

CPR services must be billed using the appropriate modifiers listed below. Also refer to Section 19 for a complete list of procedure codes and the corresponding modifiers.

13.15.A MODIFIERS

MODIFIER DESCRIPTION

HO........................Master’s level

HH........................Mental health/substance abuse program

HQ........................Group Setting



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52..........................Reduced services

TN ........................Rural/outside providers customary service area

EP.........................Services provided as part of MO HealthNet EPSDT Program

The following CPR services are covered for MO HealthNet eligible participants when medically necessary and the diagnosis is related to mental illness.

13.15.B INTAKE EVALUATION

At intake, each CPR provider shall complete in a format acceptable to the department, and file in the participant record an evaluation which shall include:

• Presenting problem, request for assistance, symptoms and functional deficits;

• Personal, family, educational, treatment and community history;

• Reported physical and medical complaints and the need for screening for medical, psychiatric, or neurological assessment or other specialized evaluation;

• Findings of a brief mental status examination;

• Current functional strengths and weaknesses obtained through interview and behavioral observation;

• Specific problem indicators for individualized treatment;

• Existing personal support systems and current use of community resources;

• Diagnostic formulation;

• Specific recommendations for further evaluation and treatment;

• Consultation between a physician and the psychologist or other mental health professional(s) conducting the psychosocial/clinical evaluation addressing the participant's need and the appropriateness of outpatient rehabilitation. Consultation may be performed by an advanced practice nurse if that individual is providing medication management services to the participant; and

• The clinical record must support the level of care.

13.15.C ANNUAL EVALUATION

An annual evaluation consists of updating annually any elements from the intake evaluation that have changed. Participants in the rehabilitation and intensive levels of care shall have annual evaluations completed. A comprehensive annual evaluation (procedure code H003152) includes all of the following components.



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• Presenting problem and request for assistance;

• Changes in personal, family, educational, treatment and community history;

• Reported physical/medical complaints;

• Current functional weaknesses and strengths;

• Changes in existing personal support systems and use of community resources;

• Description of the participant's apparent change in condition from one year ago;

• Specific problem indicators required by the department;

• Update of the diagnostic formulation;

• Specific recommendations for further evaluation and/or treatment;

• Information obtained through interview and behavioral observations that contribute to the formulation of a new treatment plan; and

• Consultation between a physician and/or psychologist and the mental health professional(s) conducting the psychosocial/clinical evaluation addressing the participant's need and appropriateness for continued outpatient rehabilitation.

13.15.D TREATMENT PLANNING

Treatment planning is covered for the development, review and/or revision of a participant's treatment/rehabilitation plan including documentation. An individualized treatment/rehabilitation plan is a document that sets forth the care, treatment and rehabilitation goals and objectives for individuals with mental illness and that details the treatment program as required by law, rules and funding sources. An Individual Treatment Plan (ITP) is required for each CPR participant. Planning includes the participant's and/or other concerned individual's input and participation.

The Individual Treatment Plan shall be completed no later than 30 days after admission; however, it should be completed earlier if clinically indicated. A physician shall approve the treatment plan. A licensed psychologist may approve the treatment plan only in instances when the participant is currently receiving no prescribed medications and the clinical recommendations do not include a need for prescribed medications. An advanced practice nurse may approve the treatment plan if that individual is providing medication management services to the participant. The participant shall participate in the development of the treatment plan and sign the plan, unless detrimental to their well-being. If the participant does not sign the treatment plan, the CPR provider shall insert a progress note in the case record explaining the reason the participant did not sign the treatment plan.



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The CPR provider shall develop and maintain for each participant an Individual Treatment Plan using a standardized format furnished by the department, at its discretion, which is filed in the master participant record.

The treatment plan shall record at a minimum; the following as indicated:

1) Service data.

• the reason(s) for admission into rehabilitation services;

• criteria or plans, or both for movement;

• criteria for discharge;

• a list of agencies currently providing program/services, the type(s) service, date(s) initiation of program/services;

• a summary statement of prioritized problems and assets; and

2) Treatment goals and objectives for the treatment plan and any components.

• specific individualized medication, psychosocial rehabilitation, behavior management, critical intervention, community support goals and other services and interventions as prescribed by the team;

• the treatment regime, including specific medical and remedial services, therapies and activities that will be used to meet the treatment goals and objectives;

• a projected schedule for service delivery that includes the expected frequency and duration of each type of planned therapeutic session or encounter;

• the type of personnel who will be providing the services;

• a projected schedule for completing reevaluations of the participant's condition and for updating the treatment plan .

• resources required to implement recommended services;

• a schedule for periodic monitoring of the participant that reflects factors which may adversely affect participant functioning

• level of care

The Individual Treatment Plan shall be reviewed on a regular basis, as determined by Department of Mental Health policy and rewritten annually. An evaluation team, consisting of at least, a qualified mental health professional (QMHP) and the participant's community support worker, if appropriate, shall review the treatment plan, goals and objectives. The review shall determine:



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• the participant's progress toward treatment objectives;

• the appropriateness of the services being furnished;

• the need for the patient's continued participation in specific community psychiatric rehabilitation services.

For participants in the rehabilitation level of care, treatment plans shall be reviewed at a minimum, every 90 calendar days and the review documented in the case record.

13.15.E BRIEF EVALUATION - QMHP

Includes screening, assessment, development and revision of an individual treatment plan for the purposes of establishing participant eligibility in a defined level of care by a QMHP.

13.15.F LIMITATIONS (FOR BOTH INTAKE AND ANNUAL EVALUATIONS/TREATMENT PLAN)

• Evaluation services are limited to one initial intake or annual evaluation per participant per provider during an 11 month period beginning with the initial intake.

Generally, it is expected that only one intake evaluation is performed for each participant per lifetime. If the participant changes providers, the new provider should obtain the intake evaluation from the prior provider. Special circumstances requiring an additional intake evaluation should be explained in a written request to DMH.

• The rate for initial intake and annual evaluation includes the cost of treatment planning.

13.15.G DOCUMENTATION REQUIREMENTS (FOR BOTH INTAKE AND ANNUAL EVALUATIONS\TREATMENT PLAN)

The psychosocial/clinical assessment and treatment plan must be completed in a standardized format required by DMH. Reference Section 14.

All treatment plans must be maintained in the participant's clinical record. PROC CODE

DESCRIPTION

H0031...............Comprehensive Intake Evaluation/Treatment Plan

H003152...........Comprehensive Annual Evaluation/Treatment Plan

90801HO..........Brief Evaluation QMHP

13.15.H CRISIS INTERVENTION AND RESOLUTION



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Crisis intervention and resolution (procedure code H2011), face-to-face emergency or telephone intervention services are available 24 hours a day on an unscheduled basis to the individual. The services are designed to resolve the crisis, provide support and assistance, and to promote a return to routine adaptive functioning. Crisis intervention is reimbursable only when the participant's community support worker is unavailable or unable to resolve a particular situation.

Key service functions for crisis intervention action include:

• Interacting with identified participant family members, legal guardian, significant others, or a combination of these;

• Specifying factors that led to the participant's crisis state, when known;

• Identifying maladaptive reactions exhibited by the participant;

• Evaluating potential for rapid regression;

• Attempting to resolve the crisis; and

• Referring the participant for treatment in an alternative setting, when indicated.

Treatment is designed to resolve the participant's presenting crisis, furnish support and assistance, develop symptomatic relief and facilitate return to routine adaptive functioning.

The service must be provided by a QMHP as defined in 9 CSR 30-4.030 and in Section 13.9.B of the manual.

Non-medical staff providing crisis intervention and resolution shall have immediate 24 hour telephone access to consultation with a physician.

13.15.H(1) Limitations

Reimbursement for crisis intervention is not allowable when the service is provided by the participant's community support worker.

13.15.H(2) Documentation Requirements

When billing for crisis intervention and resolution (procedure code H2011), the following written documentation must be maintained in the participant's clinical record:

• Description of the precipitating event(s)/situation when known;

• Description of the participant's mental status;

• Interventions initiated to resolve the participant's crisis state;

• Participant's response to intervention;



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• Disposition;

• Planned staff follow-up; and

• Other documentation requirements for each session, service and activity as specified in Section 13.4.

PROC CODE

DESCRIPTION

H2011.........Crisis Intervention & Resolution

13.15.I PRIOR CONTENTS NO LONGER APPLICABLE

13.15.J MEDICATION SERVICES

Medication services (procedure code 90862, 90862EP, 9086252, 90862TN and 90862TNEP consist of goal oriented interaction regarding the need for psychoactive medications and management of the medication regimen.

Key service functions include, but are not limited to:

• an assessment of the participant's presenting condition;

• a mental status exam;

• a review of symptoms and medication side effects;

• a review of participant functioning;

• assessment of the participant's ability to self-administer medications;

• participant education regarding the effects of medication and its relationship to the participant's mental illness; and

• prescription of medications, when indicated.

This service is covered by advanced practice nurses and psychiatric pharmacists, subject to guidelines and limitations promulgated for each specialty in statutes and administrative rules. Psychiatric pharmacists are allowed to provide all key service functions with the exception of prescribing medications. A physician shall review and evaluate medications at least every six months.

13.15.J(1) Documentation Requirements

The following written documentation must be maintained in the participant's clinical record:

• Description of the participant's presenting condition;



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• Pertinent medical and psychiatric findings;

• Observations and conclusions;

• Participant's response to medications;

• Actions and recommendations regarding the participant's ongoing medication regimen;

• Pertinent/significant information reported by family members or significant others regarding a change in the participant's condition, an unusual or unexpected occurrence in the participant's life, or both; and

• Additional items as required for each service, session, or activity as specified in Section 13.4.

Medication Services must occur at least every 6 months for anyone on psychiatric medications. Review of relevant documentation in the participant record, such as progress notes and treatment plan reviews, shall constitute the review and evaluation.

PROC CODE

DESCRIPTION

90862 .........Medication Service

90862EP.....Medication Service (Child Psychiatrist)

9086252 .....Medication Services/Professional (APN and Psychiatric Pharmacist)

90862TN ....Telepsychiatry, Medication Service

90862TNEPTelepsychiatry, Medication Service (Child Psychiatrist)

13.15.K MEDICATION ADMINISTRATION

Medication administration (procedure code H2010) consists of the administration of MO HealthNet covered injectable psychotropic medication (a therapeutic injection of medication {subcutaneous or intramuscular}) . Key service functions include:

• administrating a therapeutic injection of medication (subcutaneous or intramuscular);

• monitoring lab levels including consultation with physicians, participants and caseworkers;

• coordinating medication needs with pharmacies, participants, and families, including the use of indigent drug programs (excluding the routine placing of prescription orders and refills with pharmacies);



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• setting up medication boxes;

• dropping off medications to participant residences;

• educating patient regarding medications;

• recording initial patient histories and vital signs;

• monitoring medication compliance;

• monitoring medication side- effects including the use of standardized evaluations; and

• monitoring physician orders for treatment modifications requiring patient education.

This service is covered by a physician, registered professional nurse (RN), licensed practical nurse (LPN), advanced practice nurse, or psychiatric pharmacist.

13.15.K(1) Limitations

• Services are limited to the following injectable medications:

Prolixin Decanoate, 25 mg/1 cc Haldol Decanoate, 50 mg/1 cc

13.15.K(2) Documentation Requirements

Documentation requirements are specified in Section 13.4.

PROC CODE

DESCRIPTION

H2010.........Medication Administration

13.15.L INJECTABLE MEDICATIONS

Prolixin Decanoate and Haldol Decanoate are the two injectable medications covered in the CPR Program.

13.15.L(1) Limitations

Injectable medications are covered only if administered by appropriate staff as defined under Medication Administration. Injectable medications that are not considered by accepted standards of medical practice to be a specific or effective treatment for the particular diagnosis for which they are given are not covered.

Injectable medications that exceed the frequency of duration indicated by accepted standards of medical practice that are not justified by extenuating circumstances are not covered.



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MO HealthNet reimbursement for the covered injectable medications is determined by MHD. The maximum allowed reimbursement amounts are listed in Section 19.

For certain participants, a higher dosage of psychotropic medication is required. When billing for injectable medications that exceed the above listed dosage, show the multiple increments of the administered dosage in Field 24G of the CMS-1500 claim (For example: if the dose indicated in the injection list is 1 cc but 2 cc are given, list 2 units in Field #24G). All medications must be invoiced in whole units. If fractional units of a medication are required, invoice at the next highest whole unit but pro-rate the billed amount to the actual fraction used. Thus, if 1.50 cc of Haldol D 50 is required, bill two units but $43.99 ($29.33/unit + $14.66 1/2 unit). NOTE: Total units allowed per day is four.

Only the injectable medications listed in this section are covered through CPR.

13.15.L(2) Documentation Requirements

Documentation requirements are specified in Section 13.4.

PROC CODE

DESCRIPTION

J2680..........Prolixin Decanoate 25 mg/1 cc

J1631..........Haldol Decanoate 50 mg/1 cc

13.15.M COMMUNITY SUPPORT

Services are covered when supervised by a QMHP and when provided by a mental health professional or an individual with a bachelor's degree in social work, psychology, nursing or a closely related human services field. Equivalent experience in psychiatric and/or substance abuse treatment may be substituted on the basis of one year of experience for each year of required educational training. It is also required that the community support worker complete the necessary orientation and training requirements specified by DMH. Community support assistants with a high school diploma or equivalent and applicable training required by the department may provide community support services only under the direction of a community support worker who is supervised by a QMHP.

Community support services (procedure code H0036) are face-to-face individualized rehabilitative services.

Community support consists of activities designed to ease an individual's immediate and continued adjustment to community living by coordinating delivery of mental health services



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with services provided by other practitioners and agencies, monitoring participant progress in organized treatment programs.

Key service functions include, but are not limited to:

• assessing and monitoring a participant's adjustment to community living;

• monitoring participant participation and progress in organized treatment programs to assure the planned provision of service according to the participant's individual treatment plan;

• participating in the development or revision of a specific individualized treatment plan;

• providing individual assistance to participants in accessing needed mental health services including accompanying participants to appointments to address medical or other health needs;

• providing individual assistance to participants in accessing a variety of public services including financial and medical assistance and housing, including assistance on an emergency basis, and directly helping to meet needs for food, shelter, and clothing;

• assisting the participant to access and utilize a variety of community agencies and resources to provide ongoing social, educational, vocational and recreational supports and activities;

• interceding on behalf of individual participants within the community-at-large to assist the participant in achieving and maintaining his/her community adjustment;

• maintaining contact with participants who are hospitalized and participating in and facilitating discharge planning;

• training, coaching and support in daily living skills, including housekeeping, cooking, personal grooming, accessing transportation, keeping a budget, paying bills and maintaining an independent residence;

• assisting in creating personal support systems that include work with family members, legal guardians or significant others regarding the needs and abilities of an identified participant;

• encouraging and promoting recovery efforts, participant independence/self-care and responsibility; and

• providing support to families in areas such as treatment planning, dissemination of information, linking to services, and parent guidance.



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13.15.M(1) Limitations

The CPR provider shall ensure that an adequate number of appropriately qualified staff is available to support the functions of the program. The department shall prescribe caseload size and supervisory to staff ratios as necessary.

Community support services should not exceed four hours per day unless exception criteria are met. If met, the services cannot exceed eight hours a day. The total number of hours of community support allowed per month is 24. Contact the Department of Mental Health (DMH), Division of Comprehensive Psychiatric Services (CPS) for exception criteria.

13.15.M(2) Documentation Requirements

In order to bill for community support (procedure code H0036) written documentation must be maintained in the participant's clinical record as required for each session, service or activity. See Section 13.4. Additional documentation should include any of the following:

• Phone contact reports; and/or

• Pertinent/significant information reported by family members or significant others regarding a change in the participant's condition and/or an unusual or unexpected occurrence in the participant's life.

PROC CODE

DESCRIPTION

H0036.........Community Support

13.15.N INTENSIVE COMMUNITY PSYCHIATRIC REHABILITATION

Intensive community psychiatric rehabilitation is a level of support designed to help participants who are experiencing an acute psychiatric condition, to be served in the community alleviating or eliminating the need to admit them into a psychiatric hospital or residential setting. It is a comprehensive, time limited, community based service delivered to participants who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner .

The intensive community psychiatric rehabilitation is intended for the following participants:

• Persons who would be hospitalized without provision of intensive community based interventions; or



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• Persons who have extended or repeated hospitalizations; or

• Persons who have crisis episodes; or

• Persons who are at risk of being removed from their home or school to a more restrictive environment; or

• Persons who require assistance in transitioning from a highly restrictive setting to a community-based alternative, including specifically persons being discharged from inpatient psychiatric settings who require assertive outreach and engagement

Intensive community psychiatric rehabilitation is provided by treatment teams delivering services that will maintain the participant within the family and significant support systems and assist participants in meeting basic living needs and age appropriate developmental needs.

A treatment team comprised of individuals required to provide specific services identified on the Individualized Treatment Plan (ITP), delivers this level of service to participants who meet the community psychiatric rehabilitation (CPR) eligibility criteria.

Admission criteria for persons for this level of service must meet admission criteria as defined in Section 13.14. Persons will be in need of intensive clinical intervention or support to alleviate or eliminate the need for admission into a psychiatric inpatient or restrictive living setting and must meet one of the following descriptions:

• A person who is being discharged from a Department of Mental Health facility or Department of Mental Health purchased bed;

• A person who has had extended or repeated psychiatric inpatient hospitalizations or crisis episodes within the past six (6) months;

• A person who has had multiple out-of-home placements due to their mental disorder; or

• A person who is at imminent risk of being removed from his/her home, school or current living situation.

Intensive CPR shall be delivered by a treatment team responsible for coordinating a comprehensive array of services available to the individual through CPR with amount of frequency of service commensurate with the individual's assessed acuity and need.

The treatment team shall be supervised by a Qualified Mental Health Professional as defined in 9 CSR 30-4.030 (2) (HH) and shall include the following:

1. Individuals required to provide specific services identified on the ITP; and



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2. The participant, and family if developmentally appropriate.

Treatment team models shall follow one of two options:

1. The treatment team may serve exclusively individuals enrolled in the intensive CPR level; or,

2. The treatment team may serve individuals enrolled in intensive CPR and individuals enrolled in rehabilitation levels.

Intensive CPR shall include:

1. Multiple face-to-face contacts on a weekly basis and may require contact on a daily basis;

2. Services that are available twenty-four(24) hours per day and seven(7) days per week;

3. Crisis response services that may be coordinated with an existing crisis system.

A full array of CPR services as defined in 9 CSR 30-4.043 shall be available to each individual based upon identified needs. In addition, the following services are available:

1. Outreach and engagement;

2. Behavioral aide/family assistance worker;

3. Targeted case management;

4. Clinical interventions for the purpose of stabilizing the individual offered twenty-four(24) hours per day and seven(7) days per week;

5. Increased services to assist the individual with medication stabilization;

6. Utilization of natural services and supports needed to maintain the individual in the community;

7. Day treatment.

The frequency of service delivery shall be based upon the individual's assessed acuity and need.

Individuals can be moved out of the intensive level when:

1. There is a reduction of acute symptoms; and

2. The individual is able to function in the rehabilitation level of CPR; or

3. The individual chooses to move from the intensive level.



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13.15.N(1) Limitations

All services provided in Intensive CPR must have documentation in the form of progress notes that include:

• Specific type of service rendered as defined in the CPR menu of services;

• Date and actual time the service was rendered;

• Who rendered the service;

• The setting in which the service was rendered;

• The amount of time it took to deliver the service;

• The relationship of services to the treatment regimen described in the treatment plan;

• Updates describing the participant's response to prescribed care and treatment; and

• Signature and position of staff member delivering the service.

PROC CODE

DESCRIPTION

H0037......... Intensive Community Psychiatric Rehabilitation

13.15.O COMMUNITY SUPPORT ASSISTANT

A community support assistant is an individual with a high school diploma or equivalent and has applicable training as required by the department to assistant participants in community support services. A community support assistant is under the direction of a community support worker and supervised by a qualified mental health professional.

Services include the following:

• Providing individual assistance to participants in accessing needed mental health services including accompanying participants to appointment to address medical or other health needs;

• Providing individual assistance to participants in accessing a variety of public services including financial and housing; including assistance on an emergency basis, and directly helping to meet needs for food, shelter, and clothing;



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• Assisting participants to access and utilize a variety of community agencies and resources to provide ongoing social, educational, vocational and recreational supports and activities;

• Training, coaching, and supporting in daily living living skills, including housekeeping, cooking, personal grooming, accessing transportation, keeping a budget, paying bills and maintaining an independent residence;

• Accompanying participants to activities in the community if appropriate;

• Following up with participants regarding appointments, completion of forms, returning forms or receipts and other similar activities.

13.15.O(1) Limitations

Community support assistants may not be assigned an independent participant caseload, and may receive assignments and direction from a community support worker.

PROC CODE

DESCRIPTION

H0038.........Community Support Assistant

13.15.P PSYCHOSOCIAL REHABILITATION

Psychosocial rehabilitation services (procedure code H2017) cover a combination of goal-oriented service functions delivered through a group activity in the context of a therapeutic community which promotes development of a personal support system, social skill development, training and rehabilitation in community living skills and pre-vocational skills according to individual need. Transportation to and from community facilities is provided or arranged by the CPR provider.

Key service functions include the following:

• Initial screening to evaluate the appropriateness of the participant's participation in the program;

• Development of individualized program goals and objectives;

• The provision of rehabilitative services which may occur during the day, evenings, weekends or a combination of these. Services should be structured, but are not limited to a program site;

• Services that enhance independent living skills;



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• Services that address basic self-care needs;

• Services that enhance the use of personal support systems;

• Transportation to and from community facilities and resources as a part of program strategies;

• Services shall be provided according to individual need toward goals of community inclusion, integration, and independence; and

• Services should be available to adults as well as children and youth who need age-appropriate developmental focused rehabilitation.

13.15.P(1) Limitations

Psychosocial rehabilitation services are limited to six hours or 24 fifteen minute units per day.

13.15.P(2) Documentation Requirements

In order to bill for psychosocial rehabilitation, the following documentation must be maintained:

1. A weekly note that summarizes specific services rendered, participant response to the services, and pertinent information reported by family members or significant others regarding a change in the participant's condition, or an unusual/unexpected occurrence in the participant's life, or both; and

2. Daily attendance records or logs that include actual attendance times, as well as activity or session attended. These program attendance records/logs must be available for audit and monitoring purposes, however integration into each clinical record is not required.

PROC CODE

DESCRIPTION

H2017.........Psychosocial Rehabilitation

13.15.Q CONSULTATION SERVICES

Physician consultation and professional consultation are medical services provided by a physician, an advanced practice nurse, or a psychiatric pharmacist and consists of a review of a participant's current medical situation either through consultation with one staff person or in team discussions related to the specific participant. The intent is to provide direction to



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treatment. This is an optional service which may not substitute for supervision nor for face-to-face intervention with participants.

Services include the following:

• An assessment of the participant's presenting condition as reported by staff;

• Review of treatment plan;

• Participant-specific consultation to staff especially in situations which pose high risk of psychiatric decompensation, hospitalization or safety issues;

• Participant-specific recommendations regarding high risk issues and when needed to promote early intervention.

13.15.Q(1) Limitations

This service is only covered when provided by a physician or psychiatrist or psychiatric pharmacist and advanced practice nurse.

PROC CODE

DESCRIPTION

99241 .........Physician Consultation

99241EP.....Physician Consultation (Child Psychiatrist)

9924152 .....Professional Consultation (APN and Psychiatric Pharmacist)

99241TN ....Telepsychiatry, Physician Consultation

99241TNEP Telepsychiatry, Physician Consultation (Child Psychiatrist)

Physician time is already included in the rates for intake evaluation, annual evaluation and treatment planning. Physician consultation should not be billed separately in these instances.

13.15.R CO-OCCURRING SERVICES

13.15.R(1) Co-Occurring Individual Counseling

This service is a structured, goal-oriented therapeutic process in which an individual interacts on a face-to-face basis with a counselor in accordance with the participant's rehabilitation plan in order to resolve problems related to the participant's documented mental disorders and substance use disorders that interfere with the participant's functioning. Individual co-occurring counseling



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involves the use of evidence-based practices such as motivational interviewing, cognitive behavior therapy and relapse prevention. Individual co-occurring counseling may include face-to-face interaction with one or more members of the participant's family for the purpose of assessment or supporting the participant's recovery. Eligible providers must be either a qualified mental health professional (QMHP) or a qualified substance abuse professional (QSAP) and meet co-occurring counselor competency requirements established by the Department of Mental Health.

PROC CODE

DESCRIPTION

H0004 HH........ Co-Occurring Individual Counseling

13.15.R(2) Co-Occurring Group Counseling

Co-occurring group counseling is a face-to-face, goal-oriented therapeutic interaction among a counselor and two or more participants as specified in individual rehabilitation plans designed to promote participants' self-understanding, self-esteem and resolution of personal problems related to the participant's documented mental disorders and substance use disorders through personal disclosure and interpersonal interaction among group members. This service utilizes evidence-based practices. Eligible providers must be either a QMHP or a QSAP and meet co-occurring counselor competency requirements established by the Department of Mental Health. Group size may not exceed 10 participants.

PROC CODE

DESCRIPTION

H0005 HH........ Co-Occurring Group Counseling

13.15.R(3) Co-Occurring Group Education

These informational and experiential services are designed to assist individuals, family members, and others identified by the individual as a primary natural support, in the management of substance use and mental health disorders. Services are delivered through systematic, structured, didactic methods to increase knowledge of mental illnesses and substance use disorders which includes integrating emotional aspects in order to enable the participants, as well as family members, cope with the illness and understand the importance of their individual plan of care. The primary goal is to restore lost functioning and promote



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reintegration and recovery through knowledge of one's disease, symptoms, understanding of the "triggers" of crisis, crisis planning, community resources, recovery management, medication action and interaction, etc. Co-occurring group education focuses on evidence-based practices such as promotion of patient participation in peer self-help, brain chemistry and functioning, latest research on illness causes and treatments, medication education and management, symptom management; behavior management; stress management; improving daily living skills, independent living skills; etc. Group size is limited to 20 participants. Eligible providers must have documented education and experience related to the topic presented and either be or be supervised by a QMHP or a QSAP who meets co-occurring counselor competency requirements established by the Department of Mental Health.

PROC CODE

DESCRIPTION

H0025 HQ HH. Co-Occurring Group Education

13.15.R(4) Co-Occurring Assessment Supplement

Participants with suspected co-occurring substance use disorders and mental disorders must receive additional assessments to document the co-occurring disorders and assess the interaction of the co-occurring disorders over time. The completion of the co-occurring assessment is documented by the submission to the Department of Mental Health of data required by the Department, and the development of a comprehensive integrated treatment plan which utilizes evidence-based practices to address problems related to the co-occurring disorders. Eligible providers must be either a QMHP or a QSAP and meet co-occurring counselor competency requirements established by the Department of Mental Health.

PROC CODE

DESCRIPTION

H0031 HH....... Co-Occurring Assessment Supplement

Limit one per treatment episode and annual reassessments if needed.

13.15.S ORGANIZED HEALTH CARE DELIVERY SYSTEM (OHCDS)

Division of Community Psychiatric Rehabilitation providers are to consult with DMH regarding questions about CPR/OHCDS.



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13.16 LABORATORY SERVICES

Laboratory services are not covered through CPR. Laboratory services may be reimbursable to other appropriate MO HealthNet enrolled provider types subject to program limitations.

13.17 PRESCRIPTION DRUGS

The MO HealthNet Program covers only drugs, regardless of dosage forms (except for DESI drugs), produced by manufacturers that have entered into a rebate agreement with the federal government. Reimbursement for drugs is limited to MO HealthNet participating Pharmacy Providers.

13.18 MANAGED HEALTH CARE PROGRAM

CPR services are not included as a plan benefit for the MO HealthNet Managed Care Program.

13.19 ADMINISTRATIVE LOCK-IN

Some MO HealthNet participants are restricted or "locked in" to authorized MO HealthNet providers of certain services to aid the participant in proper utilization of the MO HealthNet Program. Refer to Section 1, Client Conditions of Participation, for additional information about the program and information on identifying lock-in participants.

13.20 GENERAL RELIEF PARTICIPANTS (text del. 3/08)

13.21 DIAGNOSIS CODES

The diagnosis codes are required on the CMS-1500 claim form when billing MO HealthNet and are contained in the International Classification of Diseases, Clinical Modification (ICD-CM) code book. Refer to Section 18 for further information.

13.22 QUALITY ASSURANCE

All CPR providers are surveyed at least annually to assure compliance and quality of care by the Missouri Department of Mental Health.

13.23 PRIOR CONTENTS NO LONGER APPLICABLE



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13.24 CARE MANAGEMENT ORGANIZATION

Refer to Section 1.5.K. END OF SECTION

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