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www.BlueChoiceSCMedicaid.com
Behavioral Health SPECIAL EDITION 2017
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The BlueChoice HealthPlan Medicaid Behavioral Health (BH) Medication Management program targets the specific needs of Healthy Connections members using BH medications. Our goals are to specifically improve the quality of care provided to our members and promote member adherence to prescribed medication treatments.
BlueChoice HealthPlan Medicaid conducts proactive outreach and education programs that focus on:
• Reducing polypharmacy.
• Promoting age-appropriate use of BH medications.
• Providing new start and adherence education.
The outreach and education programs also support BH-related HEDIS®* measures, such as:
• Antidepressant medication management.
• Follow-up care for children prescribed ADHD medication.
• Adherence to antipsychotic medications for individuals with schizophrenia.
• Use of multiple concurrent antipsychotics in children and adolescents.
• Use of first-line psychosocial care for children and adolescents on antipsychotics.
• Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications.
To learn more about the BH Medication Management program, call Pharmacy Operations at 800-719-4871, Monday through Friday, between 8:30 a.m. and 4 p.m. ET.
Behavioral Health Medication Management Program
*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Did You Know … Behavioral Health Resources AvailableBlueChoice Health Plan Medicaid has a team of behavioral health case managers
that can provide additional support to our members as they manage their recovery from behavioral health and substance use issues.
Our case management team consists of independently licensed behavioral health clinicians, an outreach support specialist and a peer support recovery
specialist. We provide telephone case management support to our members who have been referred to case management services from
hospitalizations, by community referral sources or their treating provider.
If you have a patient you believe might benefit from behavioral health case management services, please contact us at 866-757-8286. We welcome the opportunity to provide additional support to our members in their recovery and management of behavioral health and
substance use concerns.
ADD/ADHD Outreach Support Program LaunchedWe launched the ADHD/ADD outreach support program in late March. Our outreach specialist is making contact with the parents/guardians of members who are currently prescribed medication to offer support and to remind them of the importance of keeping follow-up appointments and remaining on medication as prescribed.
If you have a patient you believe may benefit from this program, please contact our Customer Care Center to initiate a referral to this program.
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Rehabilitative behavioral health services (RBHS) require prior authorization for most providers. Authorizations that are not resubmitted to and approved by BlueChoice HealthPlan Medicaid may result in claims denials. This notice is an update to providers of RBHS only.
Authorization Requirements For Behavioral Health Services
Clinical submission requirements for authorization requestsAdult and child — RBHS
• Use of service codes: H2014, H2017, H2030, H2037, S9482 and H0038, which are defined as RBHS codes by BlueChoice HealthPlan Medicaid
• Prior authorization form (specific to your agency or the Rehabilitative Behavioral Health Services Treatment Review and Authorization Request Form found on the BlueChoice HealthPlan Medicaid site)
• Diagnostic assessment• Treatment plan of care, which includes services delivered• Any additional clinical information the provider feels
supports the request, including treatment updates if the Diagnostic Assessment is more than three months old
Note: Out-of-network providers will need to submit the same forms referenced above for participating providers.
Procedure Code
Service
90785 Interactive complexity add-on code
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical service
90832 Individual psychotherapy (20 to 30 minutes)
90833 30-minute psychotherapy add-on
90834 Individual psychotherapy (45 to 50 minutes)
90836 45-minute psychotherapy add-on
90837 Psychotherapy, 60 minutes with patient and/or family member
90838 60-minute psychotherapy add-on
90839 Crisis intervention
90840 Crisis intervention add-on
90846 Family therapy without patient
90847 Family therapy with patient
90849 Multiple family group psychotherapy
90853 Group therapy
H0002 Behavioral health screening
H0031 Diagnostic assessment — follow-up
H2000 Child and adolescent level of care utilization system
H2011 Crisis management
99201-9920599211-99215
Pharmacological management
99366 Service plan development with client
99367 Service plan development without client
H0004 Substance abuse counseling — individual (Department of Alcohol and Other Drug Abuse Services [DAODAS] only)
H0005 Substance abuse counseling — group (DAODAS only)
H0038 Peer support services (DAODAS only)
H2017 Rehabilitative psychosocial services (DAODAS only)
S9482 Family support (DAODAS only)
H0034 Medication training and support (DAODAS only)
96372 Medication administration (DAODAS only)
Core therapy services
Service codes that do not require authorization for participating providers:
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Achieve higher HEDIS scores through high-quality careThis HEDIS measure includes adult and adolescent members (13 years of age and older) with a new episode of alcohol or other drug (AOD) dependence who receive follow-up care.
Initiation of AOD treatmentThe percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
Engagement of AOD treatmentThe percentage of members who initiate treatment and who have two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
Follow-up care is particularly important for members with an initial diagnosis of AOD dependence. The metric measures if the member has a follow-up visit within the first 14 days after the initial diagnosis. Also, to ensure the member is engaged in treatment, it measures that the member has two more additional services within 30 days with the appropriate AOD diagnosis.
Ways to improve your HEDIS scoreEnsure your patients schedule the appropriate follow-up appointments. Stress the importance of follow-up care with
their health care professionals. Ensure all claims for your patients with substance abuse diagnoses contain an appropriate substance abuse diagnosis codes.
Other available resourcesYou can find more behavioral health information and tools online at www.BlueChoiceSCMedicaid.com.
How we can helpIf your office needs help scheduling a follow-up appointment with a substance use treatment provider, please call the Customer Care Center at 866-757-8286.
We provide members information on behavioral health through annual newsletters and health education materials. Contact your Provider Relations representative for more information and to request copies of educational materials.
Behavioral and physical health case management services are available for our members. For more information about our Case Management program, call the Customer Care Center at 866-757-8286.
Want to know more about our quality initiatives? Call your Provider Relations representative. www.BlueChoiceSCMedicaid.com
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
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This HEDIS measure looks at members who are 18 and older and have been diagnosed with Major Depressive Disorder. The members were newly treated with an antidepressant medication and remained on antidepressant medication treatment. There are two treatment phases for this measure:
• Effective acute phase treatment: Patients newly diagnosed and treated who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective continuation phase treatment: Patients newly diagnosed and treated who remained on an antidepressant medication for at least 180 days (six months).
Providers are encouraged to code behavioral health services correctly by the NCQA. The NCQA recognizes the following codes for major depression:
Description: ICD-10-CM diagnosisMajor depression: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
Helpful tips for providers:
• Educate your patients and their spouses, caregivers and/or guardians about the importance of:
- Staying on long-term medications.
- Consulting you before abruptly stoping medications.
- Contacting you immediately if they experience any unwanted/adverse reactions, so that their treatment can be re-evaluated.
- Scheduling and attending follow-up appointments to review the effectiveness of their medications.
- Calling your office if they cannot get their prescriptions refilled.
In addition, discuss the benefits of participating in behavioral health case management programs. Ask your patients who have a behavioral health diagnosis to provide you access to their behavioral health records if you are the PCP.
Feel free to contact your provider relations representative if you have additional questions about this measure.
Antidepressant Medication Management
Behavioral Health Carve-InBlueChoice HealthPlan Medicaid will begin managing psychiatric residential treatment for mental health and autism spectrum disorder services on July 1, 2017. If you have patients who are
currently in these services and may benefit from additional support, please contact our Customer Care Center to refer
them to case management. We will be posting information related to both of these behavioral health carve-ins
on the website.
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5®) UpdatesIn an effort to keep our providers informed of changes occurring in the behavioral health community, we wanted to share some updates from the DSM-5.
When transitioning from the DSM-IV-TR to the DSM-5, the provider community moved from use of a multiaxial system to the current use of a nonaxial system upon diagnosis. While the information included in the diagnosis remains much the same, the axes are not included in DSM-5.
Although formatted differently, the same information is found within the DSM-5 diagnostic system. DSM-5 combines DSM-IV-TR axes I-III diagnoses into one list, as shown in Table 1.
Table 1: DSM-5 Diagnosis
DSM-IV Multiaxial System DSM-5 Nonaxial System
Axis I: clinical disorder and other conditions that are focus of treatment
Axis II: personality disorder and mental retardation
Axis III: general medical conditions
Combined attention to clinical disorders, including personality disorders, intellectual disability and other conditions that are the focus of treatment and medical conditions.
Axis IV: psychosocial and environmental stressorsReason for visit and psychosocial and contextual factors via expanded list of V codes and Z codes.
Axis V: global assessment of functioning (GAF)
Disability included in notation.
World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) included as option.
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Table 2
Disorder Code Effective Oct. 1, 2016
Avoidant/restrictive food intake disorder F50.89
Binge-eating disorder F50.81
Disruptive mood dysregulation disorder F34.81
Excoriation (skin-picking) disorder F42.4
Gender dysphoria in adolescents and adults F64.0
Hoarding disorder F42.3
Obsessive-compulsive disorder F42.2
Other specified depressive disorder F32.89
Other specified feeding or eating disorder F50.89
Other specified obsessive-compulsive and related disorder F42.8
Pica, in adults F50.89
Premenstrual dysphoric disorder F32.81
Social (pragmatic) communication disorder F80.82
Unspecified obsessive-compulsive and related disorder F42.9
Additional conditions and problems relevant to the presenting symptoms, diagnoses and treatment are also listed as ICD-10-CM Z codes. These can be found in the section of DSM-5 entitled “Other Conditions That May Be a Focus of Clinical Attention.” In addition, Axis V GAF was removed from DSM-5. Alternatively, WHODAS 2.0 is included in section III of DSM-5.
We understand that our providers depend upon diagnoses for guiding treatment recommendations, identifying prevalence rates for mental health service planning, identifying patient groups for clinical and basic research and documenting important public health information. As the understanding of mental disorders and their treatments has evolved, medical, scientific and clinical professionals have focused on the characteristics of specific disorders and their implications for treatment and research. Clinical training and experience are needed to use the DSM-5 for determining a diagnosis. The diagnostic criteria identify symptoms, behaviors, cognitive functions, personality traits, physical signs and syndrome combinations; durations require clinical expertise in order to differentiate psychiatric disorders from normal life variations and transient responses to stress.
Revisions to the DSM-5 may continue to take place. In 2016, updates were made to the codes used for the diagnoses listed in Table 2. Detailed information about these updates can be viewed in an online supplement published by the American Psychiatric Association located at http://psychiatryonline.org. Select View the DSM-5 Update (Sept. 2016).
Some resources that may best help you include:
• American Medical Association, Professional Edition CPT (current procedural terminology), 2016
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013
• ICD-10-CM and ICD-10-PCS Coding Handbook 2016 7
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In this issue
84832-5-2017
Page 1 Behavioral Health Medication Management Program
Page 2Did You Know … Behavioral Health Resources Available ADD/ADHD Outreach Support Program Launched
Page 3 Authorization Requirements For Behavioral Health ServicesPage 4 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Page 5Antidepressant Medication Management
Behavioral Health Carve-In
Page 6-7
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5®) Updates
BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.
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