471 NAC 20-024. INITIAL DIAGNOSTIC INTERVIEW

024. INITIAL DIAGNOSTIC INTERVIEW. For services in this chapter to be covered by Nebraska Medicaid, the necessity of the service for the beneficiary must be established through an Iinitial Ddiagnostic Iinterview. The beneficiary must have a diagnosable mental health disorder of sufficient duration to meet diagnostic criteria that results in functional impairment which substantially interferes with or limits the beneficiary’s role or functioning within the family, job, school, or community. The initial diagnostic interview is used to determine the presence or absence of a mental health disorder, identify the problems and needs, develop goals and objectives, and determine appropriate strategies and methods of intervention for the beneficiary. This comprehensive plan of care will be outlined in the individualized treatment plan and should reflect an understanding of how the beneficiary’s particular issues will be addressed with the service. The initial diagnostic interview must occur prior to the initiation of treatment interventions and must include a baseline of the beneficiary’s current functioning and treatment needs. Except for beneficiaries receiving acute inpatient hospital services, crisis services, or substance use disorder services are not required to receive an initial diagnostic interview before services are initiated. Initial diagnostic interviews that are incomplete will not be reimbursable. 024.01 COVERED SERVICES. Initial diagnostic interviews must contain: (A) A mental health evaluation with relevant beneficiary information, mental status exam, and diagnosis; and (B) Recommendations: (i) Treatment needs and recommended interventions for beneficiary and family; (ii) Identification of who needs to be involved in the beneficiary's treatment; (iii) Overall plan to meet the treatment needs of the beneficiary including transitioning to lower levels of care and discharge planning; (iv) A means to evaluate the beneficiary's progress throughout their treatment and outcome measures at discharge; (v) Recommended linkages with other community resources; and (vi) Other areas that may need further evaluation. 024.02 PROVIDER AGREEMENT. Providers of the acute services must facilitate or perform the initial diagnostic interview. Providers of crisis intervention services must facilitate the referral to or provide the initial diagnostic interview if it has not already occurred. For providers of substance use disorder services, if a co-occurring mental health condition is known or suspected, the clinician will refer the beneficiary for an initial diagnostic interview, if the clinician is unable to also do an initial diagnostic interview by scope of practice. 024.03 involvement of the supervising practitioner. The supervising practitioner must complete the initial diagnostic interview. The supervising practitioner must work with the staff person to develop the recommendations. The supervising practitioner must sign the assessment document. 024.04 PAYMENT FOR INITIAL DIAGNOSTIC INTERVIEW. Practitioners must use the national code sets to bill for the initial diagnostic interview. The reimbursement for these codes includes interview time, documentation review, and the writing of the report and recommendations. 024.04(A) PROVIDERS OF the INITiAL DIAGNOSTIC INTERVIEW. Providers of the initial diagnostic interview must bill on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. The completed initial diagnostic interview must be included in the beneficiary file and available for review upon request. Failure to produce documentation of an initial diagnostic interview upon request, or lack of inclusion in the beneficiary file determined during review, must be cause for claim denial or refund. 024.04(B) REIMBURSEMENT. Nebraska Medicaid will provide reimbursement for one initial diagnostic interview per treatment episode. Addendums may be included if additional information becomes available. If the beneficiary remains involved continuously in treatment for more than one year, reimbursement for an initial diagnostic interview may be available annually. If the beneficiary leaves treatment prior to a successful discharge and returns for further treatment, the provider must assess the need for an addendum or a new initial diagnostic interview. A second initial diagnostic interview within a year must be prior authorized. Practitioners must use national code sets to bill for this activity. 024.05 DISTRIBUTION OF THE INITIAL DIAGNOSTIC INTERVIEW. Providers must distribute complete copies of the initial diagnostic interview to other treatment providers in a timely manner when the information is necessary for a referral and the appropriate releases of information are secured.