Rate Provisions

(1) Rates as Full Compensation. The rates under 101 CMR 305.00 will constitute full compensation for behavioral health services provided by CBHCs to publicly aided and industrial accident patients, including full compensation for necessary administration and professional supervision associated with patient care. (2) Rates of Payment. Except as otherwise provided in 101 CMR 305.03(4)(c), payment rates under 101 CMR 305.00 will be the lower of (a) the eligible provider's usual charge to the general public; or (b) the schedule of allowable rates for services provided by CBHCs as set forth in 101 CMR 305.03(4)(a). (3) Modifiers. (a) -HB: Adult program, non-geriatric. (b) -HA: Child/adolescent program. (c) -HE: Mental health program. (d) -U1: Medicaid level of care 1. (e) -HN: A service rendered by a provider with a bachelor’s degree. (f) -HO: A service rendered by a provider with a master’s degree. (g) -ET: Emergency services. (4) Fee Schedule. (a) Encounter Bundle Rates. The services incorporated into the encounter bundled rate are specified in 101 CMR 305.03(4)(a)1. 1. CBHCs must bill one T1040 flat rate encounter bundle code for the provision of any of the set designated services, regardless of the number of services provided to the individual on that date. 2. The encounter bundle rates are as follows. Service Code Modifier Service Description Payment T1040 HB Medicaid Certified Community Behavioral Health Clinic Services, per Diem (Adult Services) T1040 HA Medicaid Certified Community Behavioral Health Clinic Services, per Diem (Child/Adolescent Services) 3. The designated services provided below must be billed in conjunction with the appropriate encounter bundle code in 101 CMR 305.03(4)(a)2. The designated service codes for all services provided on the same date must be billed under one encounter bundle code, regardless of the number of services provided to the individual on that date. The bundled encounter rates incorporate the following designated services codes. Service Code Service Description Psychiatric diagnostic evaluation 90791-HA Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths) Psychiatric Diagnostic Evaluation with Medical Services Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) (Use this add-on code with an appropriate evaluation and management service code when medication management is also provided.) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) (Use this add-on code with an Service Code Service Description appropriate evaluation and management service code when medication management is also provided.) Psychotherapy, 60 minutes with patient Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) (Use this add-on code with an appropriate evaluation and management service code when medication management is also provided.) Psychotherapy for crisis, first 60 minutes Psychotherapy for crisis, each additional 30 minutes (List separately in addition to the code for primary procedure.) (Add-on code) Family psychotherapy (without the patient present), 50 minutes Family psychotherapy with patient, 50 minutes Multiple-family group psychotherapy (per person session not to exceed 10 clients) Group psychotherapy (other than multiple- family group) (per person per session not to exceed 12 clients) Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions (case consultation) Interpretation or explanation of results of psychiatric, or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient (per one- half hour) Health behavior group intervention, 30 min Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (List separately in addition to code for primary service.) (add-on code) Therapeutic prophylactic or diagnostic injection (specify substance use or drug); subcutaneous or intramuscular Service Code Service Description Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date or the encounter. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 30-44 minutes of total time spent on the date of the encounter. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 45-59 minutes of total time spent on the date of the encounter Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 60-74 minutes of total time spent on the date of the encounter. Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time spent on the date of the encounter. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and Service Code Service Description straightforward medical decision making. When using time for code selection, 20-29 minutes of total time spent on the date of the encounter. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 30-39 minutes of total time spent on the date of the encounter. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 40-54 minutes of total time spent on the date of the encounter. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure), 60 min Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure) H0004 Behavioral health counseling and therapy, per 15 minutes (individual counseling) (four units maximum) (per session) H0005 Alcohol and/or drug services group counseling by a clinician (per 45-minute unit) (two units maximum) H0033 Oral medication administration, direct observation (substance use disorder programs only) T1006 Alcohol and/or substance abuse services; family/couple counseling (per 30 minutes, one unit maximum per day) (b) Crisis and Specialty Services. The MassHealth agency pays for crisis and specialty services separately from the bundled encounter rate. Crisis and specialty services may be billed on the same date of service as the encounter bundle, as clinically appropriate. Crisis intervention follow-up services may not be billed on the same day as the crisis intervention per diem service. Rates are as follows. 1. Crisis Services. Service Code Payment Rate Service Description S9485 – ET Crisis intervention mental health services, per diem. (Adult Community Crisis Stabilization per day rate) S9485 – HA, ET Crisis intervention mental health services, per diem. (Youth Community Crisis Stabilization per day rate) S9485 – HE Crisis intervention mental health services, per diem. (Adult Mobile Crisis Intervention provided at CBHC site. Inclusive of initial evaluation and first day crisis interventions.) S9485 – HA, HE Crisis intervention mental health services, per diem. (Youth Mobile Crisis Intervention provided at CBHC site. Inclusive of initial evaluation and first day crisis interventions.) S9485 – U1 $1,024.64 Crisis intervention mental health services, per diem. (Adult Mobile Crisis Intervention provided at community-based sites of service outside the CBHC site. Inclusive of initial evaluation and first day crisis interventions. Use Place of Service code 15.) S9485 – HA, U1 $1,075.87 Crisis intervention mental health services, per diem. (Youth Mobile Crisis Intervention provided at community-based sites of service outside the CBHC site. Inclusive of initial evaluation and first day crisis interventions. Use Place of Service code 15.) H2011 – HN, HB Crisis intervention service, per 15 minutes. (Adult Mobile Crisis Intervention provided at CBHC site by a paraprofessional or bachelor’s level staff. Follow- up interventions provided up to the third day following initial evaluation.) H2011 – HN, HA Crisis intervention service, per 15 minutes. (Youth Mobile Crisis Intervention provided at CBHC site by a paraprofessional or bachelor’s level staff. Follow- up interventions provided up to the seventh day following initial evaluation.) Service Code Payment Rate Service Description H2011– HO, HB Crisis intervention service, per 15 minutes. (Adult Mobile Crisis Intervention provided at CBHC site by a master’s level clinician. Follow-up interventions provided up to the third day following initial evaluation.) H2011 – HO, HA Crisis intervention service, per 15 minutes. (Youth Mobile Crisis Intervention provided at CBHC site by a master’s level clinician. Follow-up interventions provided up to the seventh day following initial evaluation.) H2011 – HN, HB Crisis intervention service, per 15 minutes. (Adult Mobile Crisis Intervention provided at a community- based site of service outside of the CBHC site by a paraprofessional or bachelor’s level staff. Follow-up interventions provided up to the third day following initial evaluation. Use Place of Service code 15.) H2011 – HN, HA Crisis intervention service, per 15 minutes. (Youth Mobile Crisis Intervention at a community-based site of service outside of the CBHC site by a paraprofessional or bachelor’s level staff. Follow-up interventions provided up to the seventh day following initial evaluation. Use Place of Service code 15.) H2011 – HO, HB Crisis intervention service, per 15 minutes. (Adult Mobile Crisis Intervention provided at a community- based site of service outside of the CBHC site by a master’s level clinician. Follow-up interventions provided up to the third day following initial evaluation. Use Place of Service code 15.) H2011 – HO, HA Crisis intervention service, per 15 minutes. (Youth Mobile Crisis Intervention provided at a community- based site of service outside the CBHC site by a master’s level clinician. Follow-up interventions provided up to the seventh day following initial evaluation. Use Place of Service code 15.) 2. Specialty Services. a. Required Services. A CBHC must have the capacity to provide the following services. These required services are not included in the encounter bundled rate and will be paid at the rates in the referenced regulations. b. For the rate for certified peer specialist services, refer to 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers. c. For community support programs, refer to 101 CMR 362.00: Rates for Community Support Program Services. d. For peer recovery coaching services, refer to 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs. e. For recovery support navigator services, refer to 101 CMR 444.00: Rates for Certain Substance Use Disorder Services. (c) Optional Services. The following services are allowed but not required to be provided by the CBHC. These optional services are not included in the encounter bundled rate. Providers are referred to the following regulations for applicable rates. 1. For psychological testing rates, refer to 101 CMR 329.00: Rates for Psychological and Independent Clinical Social Work Services. 2. For enhanced structured outpatient addiction program (E-SOAP) services, refer to 101 CMR 444.00: Rates for Certain Substance Use Disorder Services. 3. For intensive outpatient program (IOP) services, refer to 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers. 4. For structured outpatient addiction program (SOAP) services, refer to 101 CMR444.00: Rates for Certain Substance Use Disorder Services. (5) Billing. Each CBHC must bill the governmental unit according to the appropriate fee schedule on a prescribed form. Each specific service must be separately enumerated on the bill.