All Companies Writing Accident and Health Insurance and Managed Care Plans in Illinois : Company Bulletin 2020-19 Coding Solutions Determined for Bundled Treatment Models for Early Treatment of Serious Mental Illnesses

Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Illinois Department of Insurance JB PRITZKER Governor ROBERT H. MURIEL Director TO: FROM: DATE: RE: All Companies Writing Accident and Health Insurance and Managed Care Plans in Illinois Robert H. Muriel, Director December 09, 2020 Company Bulletin 2020-19 – Coding Solutions Determined for Bundled Treatment Models for Early Treatment of Serious Mental Illnesses As enacted by Pub. Act 101-461, 215 ILCS 5/356z.33(e) requires the Department to “lead and convene a workgroup… to determine a coding solution that allows for bundled treatment models to be coded and paid for as a bundle of services, similar to intensive outpatient treatment where multiple services delivered using coordinated specialty care for first episode psychosis treatment, ACT, or CST are provided and billed as a bundled services, rather than for each individual services provided by a treatment team member, which would deconstruct the evidence-based practice.” The Department convened and facilitated workgroup meetings comprised of Illinois insurance companies and mental health treatment providers that deliver bundled treatment approaches. The meetings were held on Wednesday, June 10, 2020 from 10:00 AM-11:00 AM; Wednesday, July 15, 2020 from 10:00 AM-11:00 AM; and Wednesday, August 12, 2020 from 10:00 AM- 11:00 AM; Wednesday, September 9, 2020 from 2:30 PM-3:30 PM, and Wednesday September 23, 2020 from 3:00 PM- 4:00 PM Central Time, via WebEx conference calls. The remainder of this company bulletin consists of a statement approved by the workgroup to explain the coding solution that the group has determined to allow for bundled treatment: WORKGROUP CODING SOLUTION STATEMENT Pursuant to Public Act 101-0461, the Department of Insurance convened a Workgroup of Illinois insurance companies and Illinois mental health treatment providers to determine a coding solution that allows for bundled treatment models for Coordinated Specialty Care for First Episode Psychosis (CSC), Assertive Community Treatment (ACT), and Community Support Team treatment (CST). The Workgroup recognizes that there are no existing billing codes that are a perfect match to enable billing for each of the three bundled treatment models. Until new codes are established, the Workgroup agreed to identify existing codes that are the closest fit under the circumstances in order to enable a bundled payment for the full treatment model covered, with the understanding that the services provided through these three treatment models may not match up to the official descriptions of the existing codes. Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Recommendation As a result, the Workgroup recommends the utilization of a menu of several different options that could be used by carriers and providers. While we are suggesting a code or codes under each service, there may be interchangeability between each service. CSC for First Episode Psychosis T1024 with (or without) an HK modifier 99492-99494 (see below for an option to use these three codes for all three services) ACT H0039 and H0040 CST H0036 and H0037 or H2016 AMA Code Option for all Three Services Use codes 99492-99494, along with HCPCS modifier X2, HE, and HK to identify the difference between CSC, CST, and ACT programs (see code descriptors below). These codes would allow for a team collaboration of services to be submitted with one code (two if additional time is needed). This also allows for appropriate billing of subsequent services after the initial visit. The expectation is that the licensed clinical lead on the team would be listed on the claim as the performing provider for this code set. Code Descriptions: Modifiers Modifier Description Usage X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include, but are not limited to, a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services. ACT HE Mental health program CSC HK Specialized mental health programs for high-risk populations CST AMA CPT Codes Code Description Usage 99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care ACT, CSC, and CST Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; review by the psychiatric consultant with modifications of the plan if recommended; entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies 99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation; participation in weekly caseload consultation with the psychiatric consultant; ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. ACT, CSC, and CST 99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) ACT, CSC, and CST The Workgroup recognizes the challenges facing providers to use different codes for the same services depending upon contracts with individual insurance carriers. As a result, the Workgroup recommends that carriers and providers make every available effort to use codes recommended by the Workgroup. However, the Workgroup also recognizes that some carriers may not be able to utilize any variation of the recommended codes. In those situations, the Workgroup understands that a code or codes may need to be identified and utilized outside of this recommendation to meet the requirements of Public Act 101- 0461. Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Pursuant to the statute, any code that is utilized must allow authorized providers to provide and bill for bundled services under the respective treatment models for each service. Additionally, any code utilized also must allow for services to adhere to the clinical models for each treatment as required by statute. CST and ACT contacts: Kristine Herman Bureau Chief, Behavioral Health Illinois Department of Healthcare and Family Services (217) 278-3180 Kristine.L.Herman@illinois.gov CSC contact: Sharetha Manning, LCSW Child & Adolescent Services FIRST.IL Trainer IDHS, Division of Mental Health 401 S. Clinton, 2nd Fl. Chicago, Illinois 60607 Office (312) 793-1632 Fax (312) 814-4832 Sharetha.Easter-Manning@Illinois.gov