CalAIM 行为健康计划常见问题解答
Below is a list of frequently asked questions that were collected from technical assistance and informational webinars and submissions to the BHCalAIM@dhcs.ca.gov email. DHCS will update this list on a quarterly basis.
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If a member receiving services from a MHP has a co-occurring substance use disorder (SUD), and the mental health provider’s session only focuses on the SUD need, is this acceptable? What about a DMC or DMC-ODS provider serving a member with a mental health disorder?
参考BHIN 22-013
Clinically appropriate and covered Specialty Mental Health Services (SMHS) delivered by MHP providers are covered Medi-Cal services whether or not the member has a co-occurring SUD. The reason for the service encounter (ICD-10-CM code) must correspond to the medically necessary service provided to the member. If the service is a SMHS, then the reason for the service encounter must include a ICD-10-CM code that corresponds to their mental health (see BHIN 22-013). The session must primarily address the member’s mental health, e.g. symptom, condition, diagnosis, and/or risk factors, which can include co-occurring SUD.
类似地，无论会员是否患有并发的精神健康疾病，DMC 提供商提供的临床适当且涵盖的 DMC 服务和 DMC-ODS 提供商提供的 DMC-ODS 服务分别由 DMC 县和 DMC-ODS 县承保。 如果该服务是 SUD 服务 (DMC/DMC-ODS)，则服务遭遇的原因必须包括与其 SUD 相对应的 ICD-10-CM 代码（参见BHIN 22-013 ）。 会议必须主要解决会员的药物滥用问题，例如 症状、状况、诊断和/或风险因素，可能包括同时发生的精神健康状况。
有关使用 ICD-10-CM 诊断代码/服务原因的进一步指导，请参阅 CMS 代码表（SMHS 和 DMC/DMC-ODS 服务包含的 ICD-10-CM 代码列表）和 2024 年CMS 编码指南。这些指导方针至少每年更新一次。
医疗服务提供者应使用哪些 ICD-10 代码来索取向尚未收到诊断的受益人提供的服务？
Reference BHIN 22-013
MHPs, DMC and DMC-ODS programs and providers are required to use appropriate ICD-10 diagnosis codes to submit claims to receive reimbursement of Federal Financial Participation. BHIN 22-013 identifies ICD-10 codes that may be used during the assessment phase of a member’s treatment when a diagnosis has yet to be established.