Medicaid and Special Education Psychological Services

1
Medicaid and Special Education Psychological
Services

• October 6, 2009

2
Presentation Objectives

• Recognize eligibility requirements
• Recognize those persons who can provide billable
  Psychological Services in the schools.
• Identify the already utilized Psychological
  Services that can be billed within the schools.

3
Presentation Objectives

• Understand the relationship between the schools
  Special Education process and Virginia Department
  of Medical Assistance Services (DMAS).
• Learn how to easily incorporate current
  documentation into appropriate necessary
  DMAS-compliant documentation.

4
Eligibility

• Children eligible for and enrolled in FAMIS Plus
  (childrens Medicaid) or FAMIS and
• Receiving special education services, or
• For determination of eligibility for special
  education services.

5
Psychological Services

• School providers do not require prior
  authorization.
• Services do not require a referral by a
  physician, but shall be medically prescribed by
  qualified practitioner of healing arts.

6
Psychological Services

• School-based providers of psychological
  psychiatric services are to follow the guidelines
  listed in the DMAS School Division Provider
  Manual.
• Chapter II - Provider Requirements
• Chapter IV - Covered Services
• Chapter V - Billing
• Chapter VI - Utilization Review

7
DMAS Provider Requirements

• Must be contracted by the school division AND be
  one of the following
• Licensed psychiatrist
• Licensed clinical psychologist
• Licensed school psychologist

8
Provider Requirements (cont.)

• School Psychologist-Limited
• The Board of Psychology shall license, as
  school psychologists-limited, persons licensed by
  the Board of Education with an endorsement in
  psychology and a masters degree in psychology.
  The Board of Psychology shall issue licenses to
  such persons without examination and shall
  practice solely in public school divisions

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Provider Requirements (cont.)

• License Clinical Social Worker
• Licensed Professional Counselors
• School Social Worker
• Minimum of a masters level degree and endorsed
  by Department of Education

10
Provider Requirements (cont.)

• Licensed Marriage and Family Therapist
• Licensed by DHP and Board of Counseling
• Psychiatric Clinical Nurse Specialist
• Licensed by the Board of Nursing and certified by
  the American Nurses Credentialing Center

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However

• Not every provider can provide the same services!
• Based on your training, the duties and
  responsibilities of your role within the school
  division, and the standards of professional
  practice and ethics, and
• Within guidelines of Special Education
  (8VAC20-80-10), Medicaid regulations
  (12VAC30-50-140 and 12VAC30-50-150) and School
  Division requirements.

12
State Regulations

• Medicaid State Regulations (12VAC30-50-140 and
  12VAC30-50-150)
• Psychological Evaluations/Assessments and
  counseling as a related service may be provided
  by
• Licensed by the Board of Psychology as a clinical
  psychologist, licensed school psychologist or a
  school psychologist-limited
• Psychologists (as above)
• LCSWs
• School Social Workers
• Licensed Professional Counselors
• Licensed Marriage and Family Therapists
• Psychiatric Clinical Nurse Specialist (CNS)
• Must practice within the scope of license and
  education

13
State Regulations cont.

• Department of Education (8VAC20-81 Special
  Education Regulations)
• Social work services
• Preparing a social or developmental history
• Group and individual counseling
• Working in partnership with parents and others on
  those problems in a childs living situation
• Mobilizing school and community resources
• Assisting in developing positive behavioral
  intervention strategies
• Update October 2008
• A local educational agency, in its discretion,
  may expand the role of a school social worker or
  visiting teacher beyond those services identified
  in this definition, as long as the expansion is
  consistent with other state laws and regulations,
  including licensure.

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Thinking Privately

• Requires a paradigm shift
• Translate terms and processes from a medical
  model to a special education model
• Not always easy or comfortable

15
The Process
IDEA Special Ed
Medicaid
Screening
Assessment
Eligibility
Diagnostic Clinical Interview Initial
comprehensive exam Mental Status/GAF/DSM-IV
TR 90801-90802
Psychological Testing 96101-96103
16
Screening

• Reason for referral or presenting problems
• Background information
• School/educational history
• Medical history
• Family history
• Previous psychological treatment
• Information fits on Diagnostic Clinical Interview
  form (MED 16)

17
Assessment

• Conduct a personal interview
• Continue completion of Diagnostic Clinical
  Interview Form
• Relevant Family/Medical information
• Include behavioral observations
• Conduct a diagnostic clinical interview

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Billable Psychological Services

• Initial evaluations (90801-02)
• Re-evaluations (90801-02)
• Individual and group counseling/therapy
  (90804-90857)
• Psychological Testing (96101-03)
• Neurobehavioral status exam (96116)
• Neuropsychological testing (96118-20)

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Using the Forms

• Diagnostic Clinical Interview (MED 16)
• Initial evaluations and re-evaluations
• Therapy Progress Note (MED 18)
• Individual and group counseling/therapy
• Psychological Testing Services (MED 17)
• Psychological Testing
• Neurobehavioral status exam
• Neuropsychological testing
• Psychological Services Log (MED 19)

20
Diagnostic Clinical Interview (MED 16)

• Mental Status Exam
• Similar to behavioral observations and interview
• Done all the time during an assessment, but may
  not call it this

• Appearance
• Attitude
• Eye contact
• Mood, affect
• Speech, vocabulary

• Responsiveness
• Thought process
• Judgment
• Insight
• Suicidal/homicidal

21
Diagnostic Clinical Interview (MED 16)

• For DSM-IV-TR Multiaxial System
• Axis I Clinical Disorder
• Axis II Personality Disorder/Mental Retardation
• Axis III General Medical Conditions
• Axis IV Psychosocial Environmental Problems
• Axis V Global Assessment of Functioning (GAF)
• Must have Axis I and/or II diagnosis and Axis V

22
Diagnostic Clinical Interview (MED 16)

• Include treatment plan or recommendations
• Must be performed prior to start of psychological
  services or as part of Special Education
  determination.
• Does not need to be performed annually thereafter
  unless there is a need.

23
Using Diagnosis Codes in the Schools

• For documentation purposes
• Use common diagnostic classification system -
  DSM-IV-TR
• For billing on CMS -1500 claim form
• Enter the appropriate ICD-9-CM diagnosis code

24
Using Diagnosis Codes in the Schools

• Determine appropriate and current ICD-9-CM
  diagnosis code which describes the nature of the
  illness or injury for which the service was
  rendered
• Determine if 4th or 5th digit is required

25
Using Diagnosis Codes in the Schools

• Get comfortable translating educational terms
  into psychological terms that are required for
  Medicaid billing
• Used in schools only for Medicaid documentation
• Does not have to be used in any school reporting

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Translating to" Medicaid-Friendly Terms

• Specific Learning Disabilities Learning
  Disorders
• In Reading Reading Disorder (315.00)
• In Math Mathematics Disorder (315.1)

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Translating to" Medicaid-Friendly Terms

• Mental Retardation Mental Retardation
• Educable
• Mild Mental Retardation (317)
• Trainable
• Moderate Mental Retardation (318.0)
• Severe Profound
• Severe (318.1)
• Profound (318.2)

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GAF Scale

• Psychologists judgment of students overall
  level of functioning
• Rated in respect to psychological, social and
  school functioning from 0 to 100
• 10 ranges of functioning (0-10, 11-20, etc.)
• Two components
• severity of symptoms
• functioning level

29
GAF Scale School Examples

• 30 below hospitalized, residential treatment,
  specialized programs
• 30 -40 violent, acting out
• 40 - 60 self-contained class, non-violent
  acting out, social problems
• 60 - 70 resource/itinerant services
• 70 adjustment issues, probably not special
  education guidance counseling

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Psychological Testing Form (MED 17)

• Behavioral observations
• Tests administered
• Medication at time of testing
• Plan of treatment or interventions recommended

31
Psychological Counseling (MED 18)

• Service is related to IEP
• Follows related service procedures for adding to
  IEP
• Medicaid process
• Diagnostic Clinical Interview (MED 16)
• GAF
• Treatment Plan
• Therapy Progress Note

32
DMAS Documentation Requirements

• Medicaid file NOT part of student record in
  school
• Practitioner maintains forms in files in their
  office
• Current IEP which documents need for medically
  necessary psych services

33
DMAS Documentation Requirements

• Name of child on each page
• History including school/educational, medical,
  family and previous psychological treatment
• Functional limitations
• Evidence of medical evaluation, as applicable

34
DMAS Documentation Requirements

• Intervention / Treatment Plan
• Diagnosis to be addressed by service
• Type, amount, frequency and estimated duration of
  service
• Short-term and long-term goals
• Client-specific goals related to symptoms and
  behaviors

35
DMAS Documentation Requirements

• Indicate treatment modality and reason chosen
• Signature, title and date of licensed
  practitioner of healing arts completing the POC

36
DMAS Documentation Requirements

• Reviewed every 90 days by qualified licensed
  practitioner of healing arts
• Relapse?
• Significant change in environment?
• At-risk for moving to higher level of care?
• Positive/negative changes relative to symptoms.

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DMAS Documentation Requirements

• Treatment plan available on the following forms
• Diagnostic Clinical Interview (MED 16)
• Psychological Evaluation (MED 17)
• Therapy Note (MED 18)

38
DMAS Documentation Requirements

• IEP may serve as POC and auth of services as long
  as
• Approved licensed practitioner of healing arts
  initiates the services
• IEP identified the services and estimated
  timeframe that the services will be medically
  necessary

39
DMAS Documentation Requirements

• Results of diagnostic evaluation within past year
• Record must contain diagnosis and examination
  upon which the diagnosis is based
• Licensed provider of healing arts must perform
  initial evaluation

40
DMAS Documentation Requirements

• Depending on school district policy, teachers may
  conduct annual review of students IEP to
  determine if any changes need to be made in the
  annual goals and objectives as well as
  appropriateness of the placement. Psychologists
  are typically not part of this process.

41
DMAS Documentation Requirements

• Global Assessment of Functioning
• Progress notes for ongoing services
• Evidence of the childs or parents involvement
  and understanding of diagnosis and treatment
• Entries signed and dated by responsible provider
  of services. Care rendered by personnel under
  supervision of an approved licensed professional
  must be signed by this professional every 30
  calendar days

42
DMAS Documentation Requirements

• All services must be entered in the record,
  including Treatment Plan
• Indicate progress made, change in diagnosis,
  response to treatment
• Discharge summary
• Annual summary report of therapy/counseling
  sessions
• Example Practitioner summarizes the therapy for
  IEP Team, then the documentation may be captured
  as part of the IEP renewal.

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Service Limits

• No more than a grand total of three of any in
  this list in a seven-day period
• Individual psychotherapy
• Once per day (medical/record evaluation
  management is included in the psychotherapy code
  and should NOT be billed separately)

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Service Limits (contd)

• Group psychotherapy
• Once per day
• 10 (max) per group
• No sensory stimulation, recreational activities,
  art classes, excursions, eating together counted
• Family psychotherapy
• Once per day

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Service Limits (contd)

• EXCLUSIONS
• Multiple-family group psychotherapy
• Hypnotherapy
• Environmental intervention
• Interpretation of examinations, procedures data
• Preparations of reports

46
Non-Covered Services

• Broken appointments
• Remedial education
• Day care
• Teaching grooming skills, monitoring activities
  of daily living, bibliotherapy, reminiscence
  therapy, or social interaction

47
Non-Covered Services (cont.)

• Telephone consultations
• Mail order prescriptions
• Substance abuse services (May be accessed through
  a private provider)

48
Non-Covered Services (cont.)

• Interpretation of examinations, procedures, and
  data
• The preparation of reports
• Record reviews billed separately from therapy
  session (90885 - no longer covered as of January
  1, 2007)

49
Differential Reimbursement Fees

• For the stated reimbursement amount
• 100 - Psychiatrists
• 90 - Clinical Psychologists
• 75 of the 90
• School Psychologists or School Psychologist-Limite
  d
• LCSWs or School Social Workers
• LPCs
• MFTs
• CNSs

50
Differential Reimbursement Fees

• School district (the provider) gets the federal
  share of the reimbursed fee
• Currently
• 50 for Medicaid
• 65 for FAMIS and Medicaid expansion
• July 1, 2006 Cost-based reimbursement and
  interim rates

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For Example

• A School Psychologist-Limited provider conducts a
  psychological evaluation
• 90801 Maximum interim rate 110.48
• Receives 75 of the 90 (or 67.5)
• (Clinical Psychologists full fee) 74.57
• School district would receive the federal share
  of the stated reimbursement amount 50 37.29
  or 65 48.47

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Conclusion

• DMAS required documentation readily fits into the
  current Special Education process we now follow.
• Forms can easily be adapted to be used to take
  notes during screening and during the assessment.
• Record keeping is kept to a minimum and within
  DMAS requirements.
• Forms can be hand-written or typed and
  information briefly stated.
• Additional training may be needed.

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Contact Info

• Clifford V. Hatt, Ed.D., ABPP (School), NCSP
• Coordinator, Psychological Audiological
  Services
• Director of APA-Accredited Internship Training
• Licensed Clinical Psychologist
•  Virginia Beach City Public Schools
• Ashley Barton, LCSW
• Maternal and Child Health Coordinator
• Department of Medical Assistance Services
• Ashley.Barton_at_dmas.virginia.gov
• www.dmas.virginia.gov