NOTICES
DEPARTMENT OF
HUMAN SERVICES
Medical Assistance Program Fee Schedule for Intensive Behavioral Health Services: Addition of Procedure Codes; Prior Authorization Requirements
[50 Pa.B. 741]
[Saturday, February 1, 2020]The Department of Human Services (Department) is adding new procedure codes for intensive behavioral health services (IBHS) to the Medical Assistance (MA) Program Fee Schedule effective January 17, 2020. The Department is also announcing prior authorization requirements for certain IBHS.
Background
On October 19, 2019, the Department promulgated 55 Pa. Code Chapters 1155 and 5240 (relating to intensive behavioral health services), which codified the minimum standards for licensing and MA payment conditions for agencies that deliver IBHS to children, youth and young adults under 21 years of age with mental, emotional and behavioral health needs. The regulations replaced the requirements for behavioral health rehabilitation services (BHRS) previously set forth in bulletins issued by the Department. IBHS includes individual services, applied behavior analysis (ABA) services, group services and evidence-based therapy delivered through individual services, ABA services or group services. The service array that was available through BHRS is available through IBHS.
Procedure Codes
The Department is adding new procedures codes to the MA Program Fee Schedule as well as adding modifiers to procedure codes currently on the MA Program Fee Schedule for IBHS. Following is an explanation of the procedure codes that are to be used for each IBHS, followed by a chart that includes the procedure codes, modifiers, provider type and specialties, MA fees, prior authorization requirements and MA units.
Individual Services
Individual services are delivered using behavior consultation, mobile therapy or behavioral health technician (BHT) services.
Procedure code H0032, which is currently on the MA Program Fee Schedule, will be used for behavior consultation services. This is the same procedure code currently being used for behavioral specialist consultant services through BHRS except that there no longer is a difference in rates for individuals who have a doctorate degree and individuals who have a master's degree. Instead there are different rates depending on whether or not the individual who is providing the behavior consultation services is licensed.
Procedure code H2019, which is currently on the MA Program Fee Schedule, will be used for mobile therapy services. This is the same procedure code currently being used for mobile therapy services through BHRS. There are different rates for individuals who are licensed and unlicensed that provide IBHS through mobile therapy services.
Procedure code H2021, which is currently on the MA Program Fee Schedule, will be used for BHT services. This is the same procedure code currently being used for therapeutic support staff (TSS) services through BHRS.
The Department is adding procedure code H2033 for multisystemic therapy and procedure code H2019 for functional family therapy to the MA Program Fee Schedule. These services had previously been approved through the program exception process.
ABA Services
ABA services are delivered using behavior analytic, behavior consultation—ABA, assistant behavior consulta- tion—ABA or BHT-ABA services.
The procedure codes used for BHRS did not include separate procedure codes for ABA services. Instead ABA services were billed as behavioral specialist consultant services using H0032 or behavioral specialist consultant-autism spectrum disorder services using H0046 or TSS services using H2021. Because the IBHS regulations identified ABA services as a distinct service, the Department will be adding Healthcare Common Procedure Coding System procedure codes for ABA services to the MA Program Fee Schedule, as set forth in the following chart.
The Department will be adding to the MA Program Fee Schedule procedure codes 97151, 97155 and 97156 for behavior analytic services and behavior consultation—ABA services. In addition, the Department will be adding to the MA Program Fee Schedule procedure codes 97152 and 97153 for assistant behavior consultation—ABA services and BHT-ABA services.
Group Services
The Department will be adding to the MA Program Fee Schedule procedure code 97158 for group services using ABA provided by graduate level professionals and procedure code 97154 for group services using ABA provided by individuals who are qualified to provide BHT-ABA group services.
The Department will be using procedure code H2021 for all other group services. This includes group services that had previously been approved as summer therapeutic activities programs using procedure code H2012 UB or through program exceptions.
Rates
The Department took into consideration the different requirements for providers of IBHS and the providers of BHRS in establishing the rates. The IBHS regulations include different staff qualifications, training and supervision requirements for individuals who provide IBHS. The regulations also require that an IBHS agency have an administrative director and a clinical director and include more documentation requirements.
Prior Authorization
The following services require prior authorization: BHT services, assistant behavior consultation—ABA services, BHT-ABA services and group services.
Set forth as follows are the procedure codes, modifiers, provider type and specialties, MA fees, prior authorization requirements and MA units for IBHS. The table also includes in parentheses the service that is to be billed using the procedure code.
The Department will be issuing a bulletin to MA providers with additional information.
Codes Pricing Modifier Info Modifier Description Provider Type Provider Specialty MA Fee Prior Auth. MA Unit 97151 Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessment and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment and preparing the report/treatment plan (Behavior Consultation—ABA) 11 592 $22.09 No 15 min. 97151 U7 Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessment and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment and preparing the report/treatment plan (Behavior Analytic) 11 592 $24.73 No 15 min. 97152 Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes (Behavioral Health Technician—ABA) 11 592 $12.73 Yes 15 min. 97152 U8 Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes (Assistant Behavior Consultation—ABA) 11 592 $15.76 Yes 15 min. 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes (Behavioral Health Technician—ABA) 11 592 $12.73 Yes 15 min. 97153 U8 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes (Assistant Behavior Consultation—ABA) 11 592 $15.76 Yes 15 min. 97154 U6 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes (up to 3 group members) 11 592 $16.63 Yes 15 min. 97154 U5 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes (4 to 6 group members) 11 592 $8.15 Yes 15 min. 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes (7 to 12 group members) 11 592 $5.13 Yes 15 min. 97155 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous directions of technician, face-to-face with one patient, each 15 minutes (Behavior Consultation—ABA) 11 592 $22.09 No 15 min. 97155 U7 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous directions of technician, face-to-face with one patient, each 15 minutes (Behavior Analytic) 11 592 $24.73 No 15 min. 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes (Behavior Consultation—
ABA)11 592 $22.09 No 15 min. 97156 U7 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes (Behavior Analytic) 11 592 $24.73 No 15 min. 97158 U6 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes (up to 3 group members) 11 592 $16.63 Yes 15 min. 97158 U5 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes (4 to 6 group members) 11 592 $8.15 Yes 15 min. 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes (7 to 12 group members) 11 592 $5.13 Yes 15 min. H0032 UB Mental health service plan development by nonphysician (Behavior Consultation—
Unlicensed Practitioner)11 590 $14.87 No 15 min. H0032 U9 Mental health service plan development by nonphysician (Behavior Consultation—
Licensed Practitioner)11 590 $19.56 No 15 min. H2014 UB Skills Training and Development (Onsite Supervision) 11 590 $2.50 No 15 min. H2019 Therapeutic Behavioral Services (Mobile Therapy—Unlicensed Practitioner) 11 590 $14.87 No 15 min. H2019 U9 Therapeutic Behavioral Services (Mobile Therapy—Licensed Practitioner) 11 590 $19.56 No 15 min. H2019 U6 HA Therapeutic Behavioral Services (Functional Family Therapy) 11 590 $26.01 No 15 min. H2021 U6 HQ Community-Based Wraparound Services (Group Service—4 to 8 group members) 11 591 $2.08 Yes 15 min. H2021 U5 HQ Community-Based Wraparound Services (Group Service—9 to 12 group members) 11 591 $1.57 Yes 15 min. H2021 HQ Community-Based Wraparound Services (Group Service—13 to 20 group members) 11 591 $1.06 Yes 15 min. H2021 Community-Based Wraparound Services (Behavioral Health Technician) 11 590 $9.16 Yes 15 min. H2033 Multisystemic therapy for juveniles, per 15 minutes 11 590 $28.44 No 15 min.
Fiscal Impact
The fiscal impact estimated for Fiscal Year (FY) 2019-2020 is $11.1 million ($5.3 million in State funds). The estimated fiscal impact for FY 2020-2021 is $38.5 million ($18.4 million in State funds). The estimated fiscal impact for FY 2021-2022 is $45.8 million ($21.9 million in State funds).
Public Comment
Interested persons are invited to submit written comments regarding the changes to the MA Program Fee Schedule to the Department of Human Services, Office of Mental Health and Substance Abuse Services, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, 11th Floor, Commonwealth Towers, 303 Walnut Street, Harrisburg, PA 17120. Comments may also be e-mailed to RA-PWIBHS@pa.gov. Comments received will be reviewed and considered for any subsequent revisions to the MA Program Fee Schedule.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
TERESA D. MILLER,
SecretaryFiscal Note: 14-NOT-1383. (1) General Fund;
(7) MA—Capitation; (2) Implementing Year 2019-20 is $4,916,000; (3) 1st Succeeding Year 2020-21 is $17,204,000; 2nd Succeeding Year 2021-22 through 5th Succeeding Year 2024-25 are $20,357,000; (4) 2018-19 Program—$3,303,000,000; 2017-18 Program—$3,106,000,000; 2016-17 Program—$3,657,000,000;
(7) MA—Fee-for-Service; (2) Implementing Year 2019-20 is $382,000; (3) 1st Succeeding Year 2020-21 is $1,195,000; 2nd Succeeding Year 2021-22 through 5th Succeeding Year 2024-25 are $1,529,000; (4) 2018-19 Program—$342,544,000; 2017-18 Program—$477,690,000; 2016-17 Program—$450,970,000;
(8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 20-162. Filed for public inspection January 31, 2020, 9:00 a.m.]
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