CalAIM行動健康イニシアチブのよくある質問
以下は、技術支援および情報ウェビナーから収集され、BHCalAIM@dhcs.ca.gov 電子メールに提出されたよくある質問のリストです。DHCSは、このリストを四半期ごとに更新します。
担保
患者がいない家族心理療法(CPTコード90846)は、Drug Medi-Cal(DMC)組織化デリバリーシステムで報告できるため、Specialty Mental Health(SMHS)デリバリーシステムでも報告する必要がありますか?
No. CPT code 90846 means family psychotherapyy (without the patient present). In the DMC delivery system, the definition of family therapy in the State Plan includes the following sentence, “There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of this service…” This is why CPT code 90846 is included in the DMC-ODS delivery system. The definition of therapy in the Rehabilitative Mental Health Services (i.e., SMHS) segment of the State Plan includes the sentence “Therapy may be delivered to a beneficiary or group of beneficiaries and may include family therapy directed at improving the beneficiary’s functioning and at which the beneficiary is present.” Since the definition of therapy in the SMHS delivery system explicitly requires the member to be present, CPT code 90846 is not available in SMHS.
Multiple-Family Group Psychotherapy(CPTコード90849)は、メンバーがDMC-ODS配信システムにいないときに家族療法セッションを報告するために使用できますか?
はい、できます。
CPT code 90849 means multiple-family group therapy. In the DMC-ODS delivery system, it is a family therapy code. In the Specialty Mental Health delivery system it was grouped into the family therapy service category. According to the State Plan, family therapy is defined in the State Plan as “a rehabilitative service that includes family members in the treatment process, providing education about factors that are important to the member’s recovery as well as the holistic recovery of the family system. Family members can provide social support to the beneficiary and help motivate their loved one to remain in treatment. There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of this service, but the service is for the direct benefit of the beneficiary.” Since the definition of family therapy allows it, counties may report CPT code 90849 in the DMC-ODS delivery system when the member is not present.
郡は、HCPCSコードH0007(アルコールおよび/または薬物サービス、危機介入)を使用して、DMC-ODS配信システムの危機介入の一部として付随的な接触を報告できますか?
No. HCPCS code H0007 (alcohol and/or drug services, crisis intervention), has been grouped into the SUD Crisis Intervention Services category. According to the State Plan, SUD Crisis Intervention Services “consists of contacts with a beneficiary in crisis. A crisis means an actual relapse or an unforeseen event or circumstance which presents to the beneficiary an imminent threat of relapse. SUD Crisis Intervention Services shall focus on alleviating the crisis problem, be limited to the stabilization of the beneficiary’s immediate situation, and be provided in the least intensive level of care that is medically necessary for their condition.” Since the State Plan explicitly states that SUD crisis intervention must be provided to the member, HCPCS code H0007 cannot be used to claim for a collateral contact.
郡はHCPCSコードH0032(非医師によって作成されたメンタルヘルスサービスプラン)を使用して、SMHS配信システムの付随的な接触を報告できますか?
Yes. HCPCS Code H0032, mental health service plan development by non-physician, is used to claim reimbursement for Treatment Planning. Treatment Planning is defined in the State Plan as “a service activity to develop or update a beneficiary’s course of treatment, documentation of the recommended course of treatment, and monitoring of a beneficiary’s progress.” Nothing in this definition excludes contact with significant support persons or other collaterals if the purpose of their participation is to focus on the treatment of the member. Therefore, counties may use HCPCS code H0032 to claim reimbursement for Treatment Planning.
郡はHCPCSコードH0034(投薬トレーニングとサポート)を使用して、DMC-ODSおよびSMHSデリバリーシステムの付随的な連絡先を報告できますか?
郡は、SMHS配信システムではHCPCSコードH0034を使用して担保連絡先を請求できますが、DMC-ODS配信システムでは請求できません。
HCPCS code H0034 means medication training and support. In the Specialty Mental Health System (SMHS), HCPCS code H0034 has been grouped into the medication Support service type. In the Drug Medi-Cal and the Drug Medi-Cal Organized Delivery systems (DMC and DMC-ODS), HCPCS code H0034 has been grouped into the Medication Services service type. In the State Plan, SMHS Medication Support Services are defined as services that “may include contact with significant persons or other collaterals.” However, in the DMC/DMC-ODS State Plan, the definition of Medication Services does not include contact with collaterals. Further, services that allow the member not to be present are marked with an *. Medication Services are not marked with an *. Therefore, counties cannot report H0033 and H0034 as collateral contacts in DMC and DMC-ODS delivery systems, but can report H0033 and H0034 as collateral contacts in the SMHS delivery system.
HCPCSコードH0038およびH0025(ピアサポートサービス)には、付随的な連絡先が含まれていますか?
HCPCS H0038 means one-on-one peer support services, and HCPCS code H0025 means group support services. Peer support services have been grouped into peer support in all delivery systems. The State Plan definition of peer support in all delivery systems states that “peer support services can include contact with family members or other collaterals if the purpose of the collateral’s participation is to focus on the treatment needs of the beneficiary.” Since the State Plan definition of peer support services specifically states that it includes collateral contacts, counties may use HCPCS codes H0038 and H0025 to claim for services that include collateral contacts.
リハビリテーションとリカバリーには、それぞれSMHSとDMC-ODSのデリバリーシステムに付随的な接触が含まれていますか、また、郡はHCPCSコードH2017を使用してこれらの接触を説明することができますか?
Yes. HCPCS code H2017 (Psychosocial Rehabilitation) has been grouped into the Recovery service category in the DMC-ODS delivery system and into the Rehabilitation service category in the SMHS delivery system. The State Plan defines Psychosocial Rehabilitation as an activity that “may include contact with significant support persons or other collaterals if the purpose of their participation is to focus on the treatment needs of the member. Recovery services in DMC-ODS include Care Coordination. Part of the State Plan’s definition of Care Coordination states that it entails “coordinating with ancillary services, including individualized connection, referral, and linkages to community-based services and supports.” Since the State Plan’s definition of Rehabilitation and Recovery includes collateral contacts, counties may use HCPCS code H2017 to claim for collateral contacts.
HCPCS H2021(Community-based Wrap-around service)は、メンバーが不在の場合の付随的な連絡先を説明するために使用できますか?
Yes. HCPCS code H2021 (community-based wrap-around service) was grouped into the Rehabilitation service category in the SMHS delivery system and into Treatment Planning service category in the DMC and DMC-ODS delivery systems. The State Plan defines Psychosocial Rehabilitation as an activity that “may include contact with significant support persons or other collaterals if the purpose of their participation is to focus on the treatment needs of the member. Treatment Planning is defined in the State Plan as “a service activity to develop or update a beneficiary’s course of treatment, documentation of the recommended course of treatment, and monitoring of a beneficiary’s progress.” Since the State Plan’s definition of Rehabilitation and Treatment Planning either includes collateral contacts or does not prohibit collateral contacts, counties may use HCPCS code H2021 to claim for collateral contacts whether or not the member is present.
HCPCSコードH2019に記載されている治療行動サービスには、メンバーの生物学的家族ではない個人の担保を含めることができますか?
Yes. HCPCS code H2019 (therapeutic behavioral services) was grouped into the Therapeutic Behavioral Service category. Information Notice 08-38 defines therapeutic behavioral services as services that include making collateral contacts with family members, caregivers and others significant in the life of the member whether or not the member is present. Since the Information Notice’s definition of therapeutic behavioral services includes collateral contacts, counties may use HCPCS code H2019 to claim reimbursement for collateral contact.
セラピューティック・フォスター・ケア(TFC)サービスに加えて、外来患者の傍ら的な接触を報告することはできますか?
Yes. The MHP Contract states, in part, that the Therapeutic Foster Care (TFC) “service model allows for the provision of certain specialty mental health service activities (plan development, rehabilitation and collateral) available under the EPSDT benefit as a home-based alternative to high level care in institutional settings.” Since the MHP Contract’s description of TFC states that collateral contacts that are in the plan development or rehabilitation service categories, counties may claim collateral contacts in plan development and rehabilitation service categories in addition to TFC.
対象を絞ったケースマネジメント(HCPCSコードT1017)には、付随的な連絡先が含まれていますか?
Yes. HCPCS code T1017 (targeted case management) was grouped into Referral and Linkage service category. The State Plan defines referral and linkages as services that include “identifying appropriate resources, making appointments, and assisting a beneficiary with a warm handoff to obtain ongoing support.” Since the State Plan’s definition of referral and linkages services includes collateral contacts, counties may use HCPCS code T1017 to claim reimbursement for collateral contact.
対象ケース管理(HCPCSコードT1017)が提供されている場合、メンバーは立ち会う必要がありますか?
No. HCPCS code T1017 (targeted case management) was grouped into Referral and Linkage service category. The State Plan defines referral and linkages as services that include “identifying appropriate resources, making appointments, and assisting a beneficiary with a warm handoff to obtain ongoing support.” Since the State Plan’s definition of Referral and Linkage includes services that need to be performed when the member is not present, counties can use HCPCS code T1017 to claim for services when the member is not present.
郡はH2035(アルコールおよび/またはその他の薬物治療サービス)を報告し、さらに、付随サービスを個別に報告することができますか?
Yes. HCPCS code H2035 (Alcohol and/or other drug treatment program) has been grouped into the Recovery service category in the DMC-ODS delivery system. The State Plan states that “recovery can be delivered as a standalone service, or as a service delivered as part of the levels of care listed below:
- 査定
- The definition of assessment in the State Plan includes the following: assessment “may include contact with family members or other collaterals if the purpose of the collateral’s participation is to focus on the treatment needs of the beneficiary.”
- ケアコーディネート
- The State Plan definition of care coordination includes the following component: “Coordinating with ancillary services, including individualized connection, referral and linkages to community-based services and supports.”
- カウンセリング
- The State Plan definition of individual counseling includes the following sentence: “Individual counseling can include contact with family members or other collaterals if the purpose of the collateral’s participation is to focus on the treatment needs of the beneficiary by supporting the achievement of the beneficiary’s goals.”
- The definition of family therapy in the State Plan includes the following sentence, “There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of this service, but the service is for the direct benefit to the beneficiary.”
- 家族療法
回復サービスは、付随サービスを可能にする外来サービス(評価、ケアコーディネーション、カウンセリング、家族療法)で請求できるため、郡はHCPCSコードH2035に加えて、これらのサービスカテゴリのいずれかにグループ化された付随外来サービスを請求できます。