Although care coordination did not decrease overall acute health services use, coordination improved clinical documentation of patients’ memory impairment. ED visits may have begun to decrease among patients. Finally, stress levels may have fallen among caregivers.
Conclusions: Although care coordination did not decrease overall acute health services use, coordination improved clinical documentation of patients’ memory impairment. ED visits may have begun to decrease among patients. Finally, stress levels may have fallen among caregivers.
Care coordination and caregiver support remain the primary intervention to meet the growing challenge of caring for patients with Alzheimer disease and related dementias (ADRD). Few studies, however, assessed their impact on objective measures of health care utilization. We studied patients and caregivers enrolled in the Memory Program in Greenville, South Carolina, and found strong evidence that the program led to better documentation of patients’ AD diagnosis. We also found evidence suggestive of a reduction in emergency department (ED) utilization among patients with AD and a potential reduction in urgent medical utilization for depression among caregivers.
Existing literature on ADRD interventions often focused on feasibility and self-reported outcomes.
Our studies assessed the impact of the Memory Program on objective measures of health care utilization for patients with AD.
The immediate impact may be better clinical documentation of AD even when patients seek care for other medical conditions.
There is suggestive evidence that the intervention reduced ED utilization among patients and acute medical service use for depressive symptoms among caregivers.
Health Behavior Assessment and/or Intervention (HBAI)
“Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.” 1
Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors directly affecting the patient’s physiological functioning, health and well being, or specific disease-related problems.
Indications:
For dates of service prior to 01/01/2020, the Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes (96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria:
For dates of service on or after 01/01/2020, the Health and Behavioral Assessment, initial and Reassessment should be reported with CPT code 96156, and Intervention services should be reported with CPT codes 96158, 96159, 96164, 96165.
The patient has an underlying physical illness or injury, and
There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and
The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and
The assessment is not duplicative of other provider assessments
In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient’s capacity to understand and cooperate with the medical interventions necessary to their health and well being.
Health and Behavioral Intervention, individual or group (2 or more patients) (CPT codes 96152-96153 (for dates of service prior to 01/01/2020) and CPT codes 96158, 96159, 96164, 96165 (for dates of service on or after 01/01/2020) require that:
Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, and
Psychological intervention is necessary to address:
Non-compliance with the medical treatment plan, or
The biopsychosocial factors associated with a new diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
Health and Behavioral Intervention (with the family and patient present) (CPT codes 96154/96153 (for dates of service prior to 01/01/2020) and CPT codes 96167, 96168 (for dates of service on or after 01/01/2020) is considered reasonable and necessary for the patient who meets all of the following criteria:
The family representative* directly participates in the overall care of the patient, and
The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
*For the purpose of this policy, all references to a family representative is defined as immediate family members only (i.e., husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular and sustained basis, or a guardian or healthcare proxy.
Limitations:
Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:
Does not have an underlying physical illness or injury, or
For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
Does not have the capacity to understand and to respond meaningfully during the face to face encounter, because of:
Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
disorientation to person, time, place, purpose, or
inability to recall current season, location of own room, names and faces, or
inability to recall that he or she is in a nursing home or skilled nursing facility
Does not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, or
For whom the conditions noted under the indications portion of this section are not met.
Health and Behavioral Intervention with the family and patient present will not be considered reasonable and necessary for the patient if:
It is not necessary to ensure patient compliance with the medical treatment plan, or
The family representative does not directly participate in the plan of care, or
The family representative is not present.
There is no face to face encounter with the patient.
Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT code 96155. Effective for dates of service on or after 01/01/2020, CPT code 96155 has been deleted and replaced with CPT codes 96170, 96171.
Health and Behavioral Intervention services are not considered reasonable and necessary to:
Update or educate the family about the patient’s condition
Educate family members, primary care-givers, guardians, the health care proxy, or other members of the treatment team, e.g., health aides, nurses, physical or occupational therapists, home health aides, personal care attendants and co-workers about the patient’s care plan.
Assist in treatment-planning with staff
Provide family psychotherapy or mediation
Educate diabetic patients and diabetic patients’ family members
Deliver Medical Nutrition Therapy
Maintain the patient’s or family’s existing health and overall well-being
Provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
Examples of services not covered as health and behavioral interventions are:
Stress management for support staff
Replacement for expected nursing home staff functions
Music appreciation and relaxation
Craft skill training
Cooking classes
Comfort care services
Individual social activities
Teaching social interaction skills
Socialization in a group setting
Retraining cognition due to dementia
General conversation
Services directed toward making a more dynamic personality
Consciousness raising
Vocational or religious advice
General educational activities
Tobacco or caffeine withdrawal support
Visits for loneliness relief
Sensory stimulation
Games, including bingo games
Projects, including letter writing
Entertainment and diversionary activities
Excursions, including shopping outings, even when used to reduce a dysphoric state
Teaching grooming skills
Grooming services
Monitoring activities of daily living
Teaching the patient simple self-care
Teaching the patient to follow simple directives
Wheeling the patient around the facility
Orienting the patient to name, date, and place
Exercise programs, even when designed to reduce a dysphoric state
Memory enhancement training
Weight loss management
Case management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problems
Activities principally for diversion
Planning for milieu modifications
Contributions to patient care plans
Maintenance of behavioral logs
Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must describe the patient’s condition for which the service was performed.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
CPT codes 96150-96154 may be used only by a Clinical Psychologist (CP), (Specialty Code 68). Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT codes 96156, 96167, 96168.
If the initial health and behavior assessment or reassessment (CPT codes 96150-96151) is unable to be completed during a single encounter, the date of service indicated on the claim should be the date on which the interview was finalized. Effective for dates of service on or after 01/01/2020, CPT codes 96150-96151 have been deleted and replaced with CPT code 96156.
For health and behavior assessment and/or intervention services performed by a physician, clinical nurse specialist (CNS), or nurse practitioner (NP), Evaluation and Management (E&M) or Preventive Medicine services codes should be used.
Services to patients for evaluation and treatment of mental illnesses should be coded using a psychiatric services CPT code (90801-90899).
For patients that require psychiatric services (CPT codes 90801-90899) as well as health and behavior assessment/intervention (96156, 96167, 96168), report the predominant service performed.
Do not report CPT codes 96150-96154 in addition to CPT codes 90801-90899 on the same date. CPT code 96155 is not a covered service. Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT code 96156, 96167, 96168 and CPT code 96155 has been deleted and replaced with CPT codes 96170, 96171.
Group 1 Codes:
CODE
DESCRIPTION
96156
HEALTH BEHAVIOR ASSESSMENT, OR RE-ASSESSMENT (IE, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, CLINICAL DECISION MAKING)
96158
HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; INITIAL 30 MINUTES
96159
HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96164
HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; INITIAL 30 MINUTES
96165
HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96167
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES
96168
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96170
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITHOUT THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES
96171
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITHOUT THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
CPT codes 96170, 96171 are not a covered services. Group 1 Codes.
The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Indications and Limitations of Coverage.”) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.
Because of the impact on the medical management of the patient’s disease, documentation must show evidence of coordination of care with the patient’s primary medical care providers or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address.
Documentation in the medical record by the Clinical Psychologist (CP) (Specialty Code 68) must include:
a. For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:
Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP-Specialty Code 68). Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT code 96156, 96167, 96168.
Date of initial diagnosis of physical illness, and
Clear rationale for why assessment is required, and
Assessment outcome including mental status and ability to understand and respond meaningfully, and
Goals and expected duration of specific psychological intervention(s), if recommended.
b. For re-assessment, detailed progress notes to support that the reassessment is reasonable and necessary must include the following elements:
Date of change in mental or physical status
Sufficient rationale for why re-assessment is required, and,
Clear indication of any precipitating events that necessitate re-assessment
c. For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:
Evidence that the patient has the capacity to understand and to respond meaningfully
Clearly defined psychological intervention planned
The goals of the psychological intervention
There expectation that the psychological intervention will improve compliance with the medical treatment plan
The response to the intervention
Rationale for frequency and duration of services
For all claims, the time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter must be documented in the record.
Documentation must be available to Medicare upon request.
Sources of Information:
This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.
Current Procedural Terminology, CPT 2009
Program Memorandum, Expanded Coverage of Diabetes Outpatient Self-Management Training, CR 1455, June 15, 2001
Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001
Carrier Advisory Committee Psychiatry Working Group
CPT Changes, “An Insider’s View”, 2002, American Medical Association, pages 218-220.
Lines of Business: Medicare, (some private payers)
Certain services provided by your employee (or a fellow employee) may also be eligible for Medicare payment, but check your state law for exceptions and requirements.
“Incident to” Services
Certain services provided by your employee (or a fellow employee) may also be eligible for Medicare payment, but check your state law for exceptions and requirements.
Medicare allows for the billing of “incident to” services performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished “incident to” a psychologist’s services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be:
Service Requirements to Bill
Mental health services that are commonly furnished in a psychologist’s office.
An integral, although incidental, part of the professional services performed by the psychologist.
Performed under the direct personal supervision of the psychologist.
Either furnished without charge or included in the psychologist’s bill.
Psychologists should closely review their MAC’s local coverage determinations (LCDs) for any limitations or restrictions on “incident to” services. You can view the LCDs online.
Medicare allows for the billing of “incident to” services performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished “incident to” a psychologist’s services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be:
Mental health services that are commonly furnished in a psychologist’s office.
An integral, although incidental, part of the professional services performed by the psychologist.
Performed under the direct personal supervision of the psychologist.
Either furnished without charge or included in the psychologist’s bill.
Psychologists should closely review their MAC’s local coverage determinations (LCDs) for any limitations or restrictions on “incident to” services. You can view the LCDs online.
The concept of “incident to” billing, used under Medicare Part B and sometimes adopted by private commercial third-party payers, is complicated to understand and challenging to implement for behavioral health organizations given the diversity of practitioners rendering services.
For behavioral health providers, “incident to” is an attractive option because it increases patient access to services since practitioners without a Medicare billing number, or who are not recognized by Medicare, but also not excluded, can provide care and bill under the supervising physician. The organization is then reimbursed at 100% of the physician fee schedule, as long as the guidelines are followed.
Having auxiliary staff render services and the ability to bill them as if they were rendered by the physician is a privilege granted by Medicare that requires a thorough understanding of the “incident to” rules.
This “incident to” fact sheet seeks to clarify the scope and limitations of “incident to” under Medicare as it pertains to mental health services. The intent is to assist providers and organizations avoid compliance pitfalls in the execution of “incident to” billing.
DEFINITION OF “INCIDENT TO”
“Incident to” means services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services.
The Centers for Medicare and Medicaid Services (CMS) does not provide an explicit definition of “integral, although incidental,” in its extensive description of “incident to” rules. In brief, services that would normally be part of the treatment of a patient by a physician are rendered by an auxiliary person, functioning under the direct on-premise supervision of a physician. These services are integral to implementing the physician’s established plan of treatment of an injury or illness.
WHO MAY RENDER SERVICES “INCIDENT TO” A PHYSICIAN
Mental health services rendered “incident to” a physician’s professional services are performed by auxiliary personnel such as nurses (RN or LPN) and professional clinicians not recognized by Medicare such as licensed professional counselors (LPCs) and marriage and family therapists (MFTs). Certain non-physician practitioners (NPP) also provide services under “incident to” such as a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse-midwife (CNM), licensed clinical psychologist (CP) and licensed clinical social worker (LCSW).
A word of caution; there is Medicare language that appears to support that certain NPPs such as NPs, PAs and CPs can also initiate care and have services rendered and billed under their supervision. Per a Medicare Med Learn Matters Article:
“Incident to” services are also relevant to services supervised by certain nonphysician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives or clinical psychologists. These services are subject to the same requirements as physician-supervised services. Remember that ‘incident services’ supervised by non-physician practitioners are reimbursed at 85% of the physician fee schedule. For clarity’s sake, this article will refer to ‘physician’ services as inclusive of non-physician practitioners
Be aware that NPPs may be prohibited from delegating performance of their services to auxiliary personnel under their respective state licensure laws. The Social Security Act (SSA) also requires that auxiliary personnel providing services “incident to,” must meet “any applicable requirements to provide ‘incident to’ services, including licensure, imposed by the state in which the services are being furnished
To appropriately bill and receive 100% of the physician payment under the Medicare Physician Fee Schedule (MPFS) in the outpatient office/non-hospital-based setting for mental health services, the following must occur:
The physician, (typically a psychiatrist), must initiate the course of treatment (direct, personal, professional service).5
Physicians must see all new patients, whether self-referred or sent for consultation. This allows them to establish a plan of care or treatment for each problem identified.
The initial visit by the physician may be done via telemedicine, assuming applicable Medicare rules are followed in the delivery of telemedicine. Documentation must reflect that it was a telemedicine visit and involved face-to-face contact with the patient.
Because “incident to” is “problem-centric,” if an established patient presents a new problem that results in a change in the plan of treatment, the physician must be involved to initiate the change in care.
EXAMPLE: The supervising physician on-site must be contacted by the NPP or must see the patient to approve the change(s) for the new problem; this contact is documented by the NPP and/or physician.
Because billing “incident to” requires direct, on-site supervision, contact with the physician in this scenario cannot be done via telemedicine or phone consultation.
Medicare is not prescriptive regarding what a “change” in a plan of treatment entails, so it will be important for organizations to establish the type of changes requiring physician involvement; e.g., a NP wants to prescribe a different medication for a patient or a LCSW decides their patient would benefit from eye movement desensitization and reprocessing (EMDR) to help treat a history of trauma.
There must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.
Examples to support physician active participation could include:
Documentation of face-to-face visits (can include telemedicine) with the physician as needed, notation made by a non-physician clinician that the case was discussed with the physician, and physician review and signature on the individualized plan of care.
In the office setting, qualifying “incident to” services must be provided by personnel whom you directly supervise, and who represents a direct financial expense to you (such as a “W-2” or leased employee, or an independent contractor).
Direct physician supervision of the NPP or auxiliary personnel is required.
Physician must be present in the office suite (not necessarily in same room).
Physician must be immediately available. Per the Centers for Medicare & Medicaid Services (CMS):
Immediate availability requires the immediate physical presence of the supervisory physician. CMS has not specifically defined the word ‘immediate’ in terms of time or distance; however, an example of a lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt.
SOLO PRACTITIONERS
If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.
Documentation practices that will support the appropriate rendering of “incident to” services are as follows:
Evidence of required direct supervision of the services rendered, e.g., statement by therapist on a progress note such as “Therapy rendered today under the supervision of Dr. ______, who was on-site.”
Individualized treatment plans that are reviewed per state requirements, signed and dated by a physician.
Physician order or physician intent documented for nurse visits and patient injections.
When a patient is seen by an NPP or auxiliary personnel and the patient presents with a new problem, the documentation supports that the physician was contacted regarding the new problem and determines the new course of treatment or the patient is seen by the physician prior to initiating a new course of treatment for that problem
APPLICATION & CASES
SCENARIO 1: The psychiatrist performs the initial psychiatric evaluation of the patient and develops a plan of care that includes medication management and psychotherapy. Patient is diagnosed with depression and anxiety and prescribed Zoloft 50 mg. daily. The patient is then seen monthly by a NP who makes no adjustments in the medication. A supervising psychiatrist is on-site during each appointment.
Assuming all criteria under “incident to” are met, these visits by the NP can be billed under the name/NPI of the supervising physician.
SCENARIO 2: The psychiatrist performs the initial psychiatric evaluation of the patient and develops a plan of care that includes medication management and psychotherapy. Patient is diagnosed with depression and anxiety and prescribed Zoloft 50 mg. daily. The patient is then seen monthly by a NP. At the third visit, based on the NP’s assessment of worsening symptoms, the NP decides a change to Lexapro should be considered. The NP has a hallway discussion with the supervising psychiatrist who is on-site. The physician makes the decision to change to Lexapro. The NP documents the revised order by the physician.
In this scenario, the NP determines that a change in the initial plan of care is potentially appropriate regarding the medication change. Because the physician made the ultimate decision, this visit and future visits can be billed under the name/NPI of the supervising physician since the plan of care remained the product of the physician’s decision-making
SCENARIO 3: Patient is seen weekly for psychotherapy by an LCSW. The patient calls requesting an additional appointment which the LCSW can accommodate. When the patient comes for this appointment, there is no supervising psychiatrist on-site.
The visit must be billed under the name/NPI of the LCSW and will be reimbursed at 85% of the physician fee schedule.
SCENARIO 4: Patient is seen for an initial psychiatric evaluation by the psychiatrist. The patient is diagnosed with depression and post-traumatic stress disorder. The initial plan of care includes medication management and psychotherapy.
The patient is seen for weekly psychotherapy by an LPC.
During one session, there is no supervising psychiatrist on-site. This visit is not billable as the LPC is not recognized by Medicare and does not have an NPI.
COMPLIANCE TIPS
Although “incident to” is a Medicare concept, non-Medicare payers may or may not follow Medicare’s rules for “incident to.” Be sure to contact your Medicaid and third-party payers regarding their rules for billing incident-to services and have their position in writing.
Some confusion arises in that many people use the phrase “incident to” to describe billing NPPs or other people qualifying as “auxiliary personnel” under the physician’s billing number for private insurers. Since some private insurers do not give NPPs billing numbers, they instruct the practices/clinics to bill for the NPP services under the physician’s number
MEDICARE RESOURCES
Medicare Benefit Policy Manual. Chapter 15, §60 – 60.4. This describes Medicare rules for the provision of services rendered “incident to” in office, clinic and hospital-based settings.
Medicare Benefit Policy Manual. Chapter 6, §20.5.2. This comprehensively describes coverage of outpatient, hospital based therapeutic services when rendered “incident to” a physician’s service.
Medicare Benefit Policy Manual. Chapter 6, §70 -70.3. This section describes coverage, supervision and documentation requirements for hospital based, outpatient psychiatric services.
Med Learn Matters. Article Number SE0441. Effective August 23, 2016. This article details rules for “incident to” with additional clarifications.
Med Learn Matters. Article Number SE0816. Revised May 22, 2018. This article provides an excellent summary explaining Medicare guidelines for payment of Part B mental health services.
Medicare Learning Network; MLN Booklet. Telehealth Services. January 2019. This publication addresses the core Medicare requirements in the delivery of telehealth services.
Code of Federal Regulations. 42 CFR 410.26. This section of the Federal Code describes the rules of “incident to” and provides definitions of key terms such as auxiliary personnel, direct and general supervision, practitioner and services and supplies.
Code of Federal Regulations. 42 CFR 410.71; 410.73-410.76. These portions of the Federal Code describe Medicare coverage of services to include qualifications rendered by clinical psychologists, clinical social workers, physician assistants, nurse practitioners and clinical nurse specialists. The rendering of services “incident to” a physician is also addressed under each section of the respective practitioner.
CMS. CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1717-FC), November 1, 2019. This link will go directly to the 2020 final rule. Of interest is Section X. (A) – Proposed Changes in the Level of Supervision of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals where the change is noted to general supervision for most hospital-based outpatient services. https://www.federalregister.gov/d/2019-24138/p-97
DISCLAIMER: The information presented in this document should not be considered legal advice; instead, all information, content and material presented in this publication is for general informational purposes only. Readers of this publication should contact their attorney to obtain advice with respect to any particular legal matter.
A livestream discussion to raise awareness of minority mental health. The conversation took a turn for the expected level of viewer engagement.
Mental Health is Health
Dr. Godwin Orkeh and Alex Yarijanian discuss Covid-19 and the discrepancies in access to mental health care among minority groups, including the disenfranchised, uninsured, and underinsured.
Dr. Orkeh also sheds light on the difference between equity vs. equality, the providers’ index of suspicion, health-seeking behavior among men, and the stigma associated with Covid-19.
Dr. Godwin ORKEH JR Physician, experienced Medical Director, Public Health Officer and Quality Improvement Officer, with interest in International Health and Development. A key interest of his is the interplay of culture, language and its effects (labels), and the political and socio-economic factors that influence health-seeking behavior in the population.
Alex Yarijanian CEO and founder of Carenodes, Alex is a longtime healthcare administrator, who marked his career by managing 28 safety net clinics across CA and TX, to 14 hospitals, over 50 skilled nursing facilities, to a national health plan. He is presently engaged in an effort to expand access to healthcare services, based on equity, and true to Parity between medical and mental health services.
It just so happens that July is designated as Minority Mental Health Month in the US.
As a leader in this industry, a ‘minority’ person, and someone who has to grapple with the same stigma our patient populations experience — not being hetero aware of such a designation myself, is telling of the extent to which the topic has been on the back burner (systemically).
As a leader representing a large behavioral health group in CALIFORNIA (Insight Choices), I have a personal and professional duty to do my part in leveling inequities.
As such, we have galvanized a grassroots initiative and presently we have payers, providers, and technology companies engaged.
Our coalition understands that racism undermines mental health. Therefore, we are committed to anti-racism in all that we do. This means that we pledge to work against individual racism, interpersonal racism, and institutional racism in all their forms.
We are concerned that our fellow Americans in majestic parts of this nation which also happen to be rural and are subjected to these inequities.
We are concerned that men are shamed for mental illness. We are concerned that mothers in need of mental healthcare marginalized and judged.
More and more people are starting to speak up about the unique mental health needs of this country’s diverse communities. From health care disparities that have become more apparent during COVID-19 to highlighting the need for culturally competent mental health care providers, these conversations contribute to raising awareness around critical issues.
We are strong alone, but unstoppable together. Would you pls share what activities, initiatives, and other engagement efforts you’ve implemented. If you and or your organization would love to engage but, with limited bandwidth and strained resources, has not had the opportunity to engage, pls let us know.
Health Net has grant funded a proposal by Insight Choices, in partnership with Carenodes, to expand virtual healthcare delivery capacity and accessibility. In response to the ongoing COVID-19 pandemic, Insight Choices, a coalition of psychiatric providers across California were awarded a $125,000 telehealth infrastructure expansion grant by Health Net.
The grant will help Insight Choices launch new telehealth technologies to increase its prevention and intervention efforts for patients with mental health conditions. Furthermore, availability of funding will enable the provision of crisis intervention services, mental and substance use disorder treatment, crisis counseling, and other related supports for communities impacted by the COVID-19 pandemic.
Earlier this year, Health Net announced it would award $13.4 million in immediate assistance for Medi-Cal providers to expand telehealth capacity and capabilities at California safety net clinics, Federally Qualified Health Centers (FQHC), and independent provider practices.
Providing increased access to care during this unprecedented time is critical to ensuring our most vulnerable populations stay healthy and safe. The amount of difficult news, confusion and tragedy surrounding all of us in a short period of time can feel insurmountable. Reaching out for help is incredibly important and telehealth is key to ensuring access to care is not interrupted.
Brian Ternan, President and CEO, Health Net of California and California Health & Wellness.
Recognizing the urgency of the situation, Insight Choices saw the need to increase its telehealth offering to benefit its patients who are coping with increased anxiety, deep depression and unfortunately, suicidal ideation. The organization is also seeing an increased need to provide mental health services for health care workers on the frontline of the pandemic.
“Health care providers throughout California are under incredible, and still increasing, strain as they work diligently to fight this pandemic, and for our patients, the strain they feel is just as, if not more difficult to handle,” said Robert Chang, DO, Medical Director & President at Insight Choices. “As we focus on mental health care and the emotional wellbeing of the Californians we serve, these funds will provide Insight Choices the support needed to deliver a robust response to the mental health needs exasperated by the COVID-19 pandemic.”
“Our nation’s health care providers are under incredible, and still increasing, strain as they fight the pandemic. Insight Choices plan for the COVID-19 Telehealth Program is a critical tool to address this national emergency—starting in California and the counties we serve with a focus on mental health care and emotional wellbeing. This grant will provide Insight Choices, and the communities it serves, vital funding to assist in a more robust response to the mental health crisis exasperated by the COVID-19 pandemic,”
Alex Yarijanian CEO of Carenodes and Interim COO of Insight Choices
Social distancing has led many across the nation to seek out health providers that offer telehealth to ease the anxiety of walking into a clinic, and this is no different for mental health clinics. Telehealth can also bring costs down for some patients and is a benefit to those without a mode of transportation. However, many providers and organizations that serve Medi-Cal patients face financial barriers to expand the implementation, and this is where organizations like Health Net come in.
Insight Choices and Carenodes, will support infrastructure modernization efforts to include telecommunications services, information services and devices necessary to enable the provision of telehealth services during this emergency period. In addition, such capacity building funds have the potential to substantially stimulate the deployment of innovative access to care models.
About Insight Choices Insight Choices Psychiatry and Behavioral Health Services offer a full range of assessment and treatment options to address the mental, emotional and behavioral problems that occur throughout life. The group’s programs encompass a comprehensive view of mental health integrating the biological, psychological and social dimensions of care. Serving populations across California with expanded hours (nights and weekends), telehealth availability, evidence-based treatment modalities, and engagement via technology and virtual means, Insight Choices leads access to care.
About Carenodes Carenodes leads healthcare infrastructure development efforts around integrating nonmedical services within mainstream healthcare (primary care, behavioral, substance abuse, payers). It focuses on developing provider networks with the capacity to deliver on the promise of a ‘biopsychosocial model of wellbeing’ and equity in access to healthcare.
About Health Net: Health Net believes every person deserves a safety net for their health, regardless of age, income, employment status or current state of health. Founded 40 years ago, we remain dedicated to transforming the health of our community, one person at a time. Today, Health Net’s 3,000 employees and 85,000 network providers serve more than 3 million members. That’s nearly 1 in 12 Californians. Health Net of California, Inc., Health Net Life Insurance Company and Health Net Community Solutions, Inc. These entities are wholly owned subsidiaries of Centene Corporation (NYSE: CNC), a Fortune 100 company providing health coverage to more than 20 million Americans.
Health Net’s telehealth grant gives members an alternative and convenient means to address their mental healthcare concerns
Health Net has grant funded a proposal by Insight Choices, in partnership with Carenodes, to expand virtual healthcare delivery capacity and accessibility. In response to the ongoing COVID-19 pandemic, Insight Choices, a coalition of psychiatric providers across California were awarded a $125,000 telehealth infrastructure expansion grant by Health Net.
The grant will help Insight Choices launch new telehealth technologies to increase its prevention and intervention efforts for patients with mental health conditions. Furthermore, availability of funding will enable the provision of crisis intervention services, mental and substance use disorder treatment, crisis counseling, and other related supports for communities impacted by the COVID-19 pandemic.
Earlier this year, Health Net announced it would award $13.4 million in immediate assistance for Medi-Cal providers to expand telehealth capacity and capabilities at California safety net clinics, Federally Qualified Health Centers (FQHC), and independent provider practices.
“Providing increased access to care during this unprecedented time is critical to ensuring our most vulnerable populations stay healthy and safe. The amount of difficult news, confusion and tragedy surrounding all of us in a short period of time can feel insurmountable. Reaching out for help is incredibly important and telehealth is key to ensuring access to care is not interrupted.”
Brian Ternan, President and CEO, Health Net of California and California Health & Wellness.
Recognizing the urgency of the situation, Insight Choices saw the need to increase its telehealth offering to benefit its patients who are coping with increased anxiety, deep depression and unfortunately, suicidal ideation. The organization is also seeing an increased need to provide mental health services for health care workers on the frontline of the pandemic.
“Health care providers throughout California are under incredible, and still increasing, strain as they work diligently to fight this pandemic, and for our patients, the strain they feel is just as, if not more difficult to handle,” said Robert Chang, DO, Medical Director & President at Insight Choices. “As we focus on mental health care and the emotional wellbeing of the Californians we serve, these funds will provide Insight Choices the support needed to deliver a robust response to the mental health needs exasperated by the COVID-19 pandemic.”
“Our nation’s health care providers are under incredible, and still increasing, strain as they fight the pandemic. Insight Choices plan for the COVID-19 Telehealth Program is a critical tool to address this national emergency—starting in California and the counties we serve with a focus on mental health care and emotional wellbeing. This grant will provide Insight Choices, and the communities it serves, vital funding to assist in a more robust response to the mental health crisis exasperated by the COVID-19 pandemic,”
Alex Yarijanian CEO of Carenodes and Interim COO of Insight Choices
Social distancing has led many across the nation to seek out health providers that offer telehealth to ease the anxiety of walking into a clinic, and this is no different for mental health clinics. Telehealth can also bring costs down for some patients and is a benefit to those without a mode of transportation. However, many providers and organizations that serve Medi-Cal patients face financial barriers to expand the implementation, and this is where organizations like Health Net come in.
Insight Choices and Carenodes, will support infrastructure modernization efforts to include telecommunications services, information services and devices necessary to enable the provision of telehealth services during this emergency period. In addition, such capacity building funds have the potential to substantially stimulate the deployment of innovative access to care models.
About Insight Choices Insight Choices Psychiatry and Behavioral Health Services offer a full range of assessment and treatment options to address the mental, emotional and behavioral problems that occur throughout life. The group’s programs encompass a comprehensive view of mental health integrating the biological, psychological and social dimensions of care. Serving populations across California with expanded hours (nights and weekends), telehealth availability, evidence-based treatment modalities, and engagement via technology and virtual means, Insight Choices leads access to care.
About Carenodes Carenodes leads healthcare infrastructure development efforts around integrating nonmedical services within mainstream healthcare (primary care, behavioral, substance abuse, payers). It focuses on developing provider networks with the capacity to deliver on the promise of a ‘biopsychosocial model of wellbeing’ and equity in access to healthcare.
About Health Net: At Health Net, we believe every person deserves a safety net for their health, regardless of age, income, employment status or current state of health. Founded 40 years ago, we remain dedicated to transforming the health of our community, one person at a time. Today, Health Net’s 3,000 employees and 85,000 network providers serve more than 3 million members. That’s nearly 1 in 12 Californians. Health Net of California, Inc., Health Net Life Insurance Company and Health Net Community Solutions, Inc. These entities are wholly owned subsidiaries of Centene Corporation (NYSE: CNC), a Fortune 100 company providing health coverage to more than 20 million Americans.
Even though addiction is a treatable illness, we needlessly lose thousands of lives due to a nationwide shortage of trustworthy, affordable, evidence-based care.
Tell Your Reps: Add Key Addiction Legislation to COVID-19 Stimulus!
As a member of the Shatterproof community, I am uniquely concerned about the negative impact that the COVID-19 virus will have on overdose rates, strain on the healthcare system, and the risk of relapse. The overdose crisis continues to be a national emergency. We need strong federal action now to save lives.
Even though addiction is a treatable illness, we needlessly lose thousands of lives due to a nationwide shortage of trustworthy, affordable, evidence-based care.
The societal and economic factors surrounding COVID-19, such as isolation, loss of structure, unemployment, increased stress, depression and anxiety, will undoubtedly lead to reduced engagement in addiction treatment.
The addiction treatment system is facing issues with revenue, workforce capacity, and supply of medication. Increased demand for treatment and reduced supply is a recipe for disaster.
In order to increase access to treatment for those struggling, we need to remove the buprenorphine waiver requirement. Medications, such as buprenorphine, are the most effective evidence-based treatment we have available for opioid use disorder. Especially during the global pandemic and increased number of overdoses, we need to expand access to this life-saving medication and allow providers to prescribe via telemedicine.
The Mainstreaming Addiction Treatment Act would eliminate the separate waiver, called DATA 2000 X-waiver, needed to prescribe buprenorphine for addiction treatment. We know that removing barriers to buprenorphine saves lives.
The MATE Act will require all DEA-controlled medication prescribers to receive a one-time training on treating and managing patients with addiction (unless the prescriber is otherwise qualified). It will allow accredited medical schools and residency programs, physician assistant schools, and schools of advanced practice nursing to fulfill the training requirement through a comprehensive curriculum that meets the standards specified. This will help normalize addiction medicine education across professional schools and phase out the need for these future practitioners to take a separate, federally mandated addiction training course.
Please include the Mainstreaming Addiction Treatment Act (H.R. 2482/S. 2074), and The Medication Access and Training Expansion (MATE) Act (H.R. 4974) in the COVID-19 stimulus packages to provide critical resources to those struggling with addiction and abate the forthcoming drug overdose epidemic.
With the current uptick in usage rates and anticipated overdose rates, we need to take action now to mitigate the damage on this vulnerable population amidst COVID-19.
Carenodes is a Shatterproof Ambassador organization.
Shatterproof Ambassadors are a part of a national network of volunteer peer leaders, educating and empowering others to learn about and support Shatterproof’s mission to reverse the addiction crisis in the United States. Ambassadors are committed to promoting the Shatterproof vision and representing the organization. Being a Shatterproof Ambassador is a rewarding experience that allows you to share your passion for Shatterproof’s mission.
About Shatterproof
Shatterproof is a national nonprofit organization dedicated to reducing the devastation the disease of addiction causes families.
#IBELIEVE in Maternal Mental Health Access and I will fight alongside you each and every step of the way.
Closing gaps in maternal mental health care seems like a no-brainer but, just like much of the healthcare industry, we’ve been slow to adapt and even slower in adoption.
Slow at adapting to a changing world and population needs.
Slow to adopt reasonably sound new technologies, interventions, and process innovations.
We cannot leave our mothers behind! As such, the following guidance is targeted towards payers and health insurance companies — and for us all (from community member to healthcare provider) to hold payers accountable.
2020 Mom believes change is possible in maternal mental health care. If you also believe change is possible, join us!
Here are the steps health insurance companies can take to support maternal mental health (MMH)
HEALTH PLANS & PAYERS:
Institute a case management/care coordination program, allowing obstetricians to refer moms immediately into the program who screen positive for depression, anxiety or bi-polar disorder. Medicaid plan case managers/care coordinators should also address social determinants of health, like food and housing insecurity and safety.
Inform obstetricians how to bill for screening.
Inform obstetricians how to bill for treatment (brief intervention/medication management).
Provide telepsychiatry patient to provider services for all patients with bi-polar disorder, treatment resistant depression, or severe mental illness as a standard.
Inform obstetricians that they should be treating basic depression and anxiety as prescribers when necessary, and how they can consult with a reproductive psychiatrist and bill for their time.
Reimburse obstetrians and hospitals who staff LCSWs or other talk therapists in their offices.
Cover digital therapuetics and explain to providers how to prescribe use of these tools.
MENTAL HEALTH INSURANCE COMPANIES
Identify via an attestation, on the provider credentialing form and at a recredentialing for existing providers, which providers have taken at least 8 hours of a certificate based training in maternal mental health and have 20 practice hours treating MMH disorders.
Pay providers who have earned a PMH designation (the board test provided by Postpartum Support International) higher rates.
Monitor whether you have sufficient MMH providers based on child bearing age women and location of these women in the service area and recruit as needed.
Be available to coordinate with case managers at medical insurers.
Reimburse birth hospitals or medical clinics that provide support groups for maternal mental health disorders, NICU moms/parents that are clinician or certified peer specialist lead.
Authorize services for MMH specific outpatient day treatment programs and inpatient programs. Work to recruit such programs in the provider network.
2020 Mom believes change is possible in maternal mental health care. If you also believe change is possible, join us.
This episode of “The Male Perspective” Lana sits down with Alex Yarijanian, Founder & CEO of Carenodes to discuss medical and mental health care. HELPFUL RESOURCES: National Suicide Prevention Lifeline 1-800-273-8255 Can text and/or call. “Text us for confidential support. It’s okay to not be okay. 24/7. Confidential. Free. Any Crisis. Services: Text a Crisis Counselor, Free, 24/7 support, We’re here for you, You deserve support.” Substance Abuse and Mental Health Services Administration (SAMHSA) https://www.samhsa.gov/.
Alex Yarijanian 