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Diagnostic Assessment

Revised: 10-15-2013

A diagnostic assessment (DA) is a written report that documents the clinical and functional face-to-face evaluation of a recipient’s mental health. The report must include the recipient’s:

  • • Nature, severity and impact of behavioral difficulties
  • • Functional impairment
  • • Subjective distress
  • • Strengths and resources

  • A diagnostic assessment is necessary to determine a recipient’s eligibility for mental health services.

    In addition, the DA may be performed with or without medical services. Medical services include:

  • • Prescription of medications
  • • Reviewing and ordering laboratory services
  • • Other diagnostic studies
  • Eligible Providers

  • • Licensed mental health professionals, except allied mental health professionals and adult mental health rehabilitation professionals
  • • An individual certified by tribal council as a mental health professional, serving a federally recognized tribe
  • Mental health practitioners who qualify as clinical trainees

  • Clinical supervision pertinent to recipient treatment changes must be recorded by a case notation in the recipient record after supervision occurs.

    Diagnostic assessment with medical services can be performed by:

  • • Psychiatrists
  • • Clinical Nurse Specialist-Mental Health (CNS-MH)
  • • Psychiatric Nurse Practitioner (NP)
  • Eligible Recipients

    All MHCP recipients are eligible for diagnostic assessment.

    Covered Services

    To be eligible for MHCP payment, a diagnostic assessment must:

  • • Identify a mental health diagnosis and recommend services, or determine the recipient does not meet the criteria for a mental health disorder. This is used as the factual basis to develop the recipient’s treatment plan
  • • Include a face-to-face interview with the recipient and a written evaluation. Diagnostic assessments may be conducted using telemedicine technology when appropriate
  • • Meet the conditions of one of the following four types of DA. Include a description of which of these types of DA is used in the written report:
  • • Brief Diagnostic Assessment
  • • Standard Diagnostic Assessment
  • • Extended Diagnostic Assessment
  • • Adult Diagnostic Assessment Update

  • Brief Diagnostic Assessment
    A brief DA includes:

  • • Sufficient information to apply a provisional clinical hypothesis – the clinical hypothesis may be used to address the recipient’s immediate needs or presenting problem
  • • The recipient’s current life situation, including the following:
  • • Age
  • • Current living situation (including household membership and housing status)
  • • Basic needs status including economic status
  • • Education level and employment status
  • • Significant personal relationships (including recipient’s evaluation of relationship quality)
  • • Strengths and resources (including extent and quality of social networks)
  • • Belief system
  • • Contextual non-personal factors contributing to the recipient’s presenting concerns
  • • General physical health and relationship to recipient’s culture
  • • Current medications
  • • Recipient’s description of symptoms (including reason for referral)
  • • A mental status exam
  • • Screenings used to determine a recipient’s substance use, abuse, or dependency, and other standardized screening instruments
  • • A clinical summary that explains the provisional diagnostic hypothesis

  • A brief diagnostic assessment may be used for:

  • • A new recipient
  • • An existing recipient who had less than 10 sessions of psychotherapy in previous 12 months and is projected to need ten or fewer psychotherapy session in the next 12 months
  • • An existing recipient who only needs medication management
  • • An annual assessment, if the recipient’s treatment history and provider’s clinical judgment suggest the recipient will need ten or fewer mental health sessions in the next 12 months

  • A brief diagnostic assessment must not be used:

  • • When a recipient or recipient’s family requires a language interpreter to participate, unless the recipient:
  • • Had fewer than 10 sessions of psychotherapy in the previous 12 months and is projected to need fewer than 10 sessions in the following 12 months
  • • Receives only medication management
  • • When a recipient is expected to need more than 10 sessions of mental health services in a 12 month period.

  • Standard Diagnostic Assessment
    A standard DA is conducted in the cultural context of the recipient. It includes all of the components of the brief DA, and all of the following:

  • • The reason for the assessment, including the recipient’s:
  • • Perceptions of his/her condition
  • • Description of symptoms (including reason for referral)
  • • History of mental health treatment (including review of recipient’s records)
  • • Important developmental incidents
  • • Maltreatment, trauma, or abuse issues
  • • History of alcohol and drug usage and treatment
  • • Health history and family health history, including physical, chemical, and mental health history
  • • Cultural influences and their impact on the recipient
  • • An assessment of the recipient’s needs based on:
  • • Baseline measurements
  • • Symptoms
  • • Behavior
  • • Skills
  • • Abilities
  • • Resources
  • • Vulnerabilities
  • • Safety
  • • Assessment methods and use of standardized assessment tools
  • • Clinical summary, including recommendations and prioritization of needed mental health or other services
  • • Involvement of the recipient and recipient’s family in the assessment and their preferences or referrals to services
  • • Sufficient data to support findings on all axes of the current Diagnostic and Statistical Manual (DSM), and any differential diagnosis

  • A new standard DA must be completed for a child:

  • • At least annually following the initial DA if additional services are needed
  • • When a child does not meet the criteria for a brief or extended DA
  • • When the child’s mental health condition has changed markedly since the child’s most recent DA
  • • When the child’s current mental health condition does not meet criteria of the child’s current diagnosis

  • A new standard DA may be used for an adult:

  • • At least every three years following the initial standard or extended DA for an adult who receives services
  • • When the adult does not meet the criteria for a brief DA or an adult update
  • • When the adult’s mental health condition has changed markedly since the adult’s most recent DA
  • • When the adult’s current mental health condition does not meet criteria of the adult’s current diagnosis

  • Extended Diagnostic Assessment
    An extended DA includes all components of a standard DA, gathered over three or more appointments. The recipient requires significant additional assessment time due to complex needs, caused by:

  • • Acuity of psychotic disorder
  • • Cognitive or neurocognitive impairment
  • • A need to consider past diagnoses and determine their current applicability
  • • Co-occurring substance abuse use disorder
  • • Disruptive or changing environments
  • • Communication barriers
  • • Cultural considerations

  • For child recipients:

  • • Appointments may be conducted outside the office, with or without the child present, for face-to-face consultation and information gathering with:
  • • Family members
  • • Doctors
  • • Caregivers
  • • Teachers
  • • Other providers
  • • May involve directly observing the child in various settings that the child frequents (home, school, care settings)

  • For children under age 5:

  • • Utilize the DC:0-3R diagnostic system for young children
  • • Early childhood mental status exam that assesses the child’s developmental, social, and emotional functioning/style with the family and with the examiner. The exam includes:
  • • Physical appearance including dysmorphic features
  • • Reaction to new setting and people, including adaptation during evaluation
  • • Self-regulation, including:
  • • Sensory regulation
  • • Unusual behaviors
  • • Activity level
  • • Attention span
  • • Frustration tolerance
  • • Physical aspects, including:
  • • Motor function
  • • Muscle tone
  • • Coordination
  • • Tics
  • • Abnormal movements
  • • Seizure activity
  • • Vocalization and speech production, including expressive and receptive language
  • • Thought, including:
  • • Fears
  • • Nightmares
  • • Dissociative states
  • • Hallucinations
  • • Affect and mood, including:
  • • Modes of expression
  • • Range
  • • Responsiveness
  • • Duration
  • • Intensity
  • • Play, including:
  • • Structure
  • • Content
  • • Symbolic functioning
  • • Modulation of aggression
  • • Cognitive functioning
  • • Relatedness to parents, other caregivers, and examiner
  • • Other assessment tools as determined and periodically revised by the commissioner

  • A new extended DA must be completed for a child:

  • • At least annually following the initial DA if additional services are needed
  • • When a child does not meet the criteria for a brief or standard DA
  • • When the child’s mental health condition has changed markedly since the child’s most recent DA
  • • When the child’s current mental health condition does not meet criteria of the child’s current diagnosis

  • For adult recipients:

  • • Appointments may be conducted outside the office, for face-to-face assessment with the adult
  • • May involve directly observing the adult in various settings that the adult frequents (home, school, job, service settings, community settings)
  • • May include face-to-face meetings with:
  • • The adult and family members
  • • Doctors
  • • Caregivers
  • • Teachers
  • • Social support network members
  • • Recovery support resource representatives
  • • Other providers
  • • Completion of other assessment standards for adults

  • A new extended DA must be completed for an adult:

  • • When the adult does not meet the criteria for a brief or standard DA
  • • Who has complex needs and requires at least 3 diagnostic appointments to complete the assessment, which allows further mental health services for one year
  • • When the adult’s mental health condition has changed markedly since the adult’s most recent diagnostic assessment
  • • When the adult’s current mental health condition does not meet criteria of the adult’s current diagnosis

  • Adult Diagnostic Assessment Update
    For adults age 18 and over, use an adult DA update to revise a standard or extended DA that has occurred:

  • • Within the past 12 months
  • • Within the past 24 months, when a previous adult diagnostic assessment update has occurred within the past 12 months

  • An adult DA update must include:

  • • Review of the recipient’s life situation
  • • Significant new or changed information; or document where there has not been significant change
  • • Screenings for substance use, abuse, or dependency
  • • Mental status exam
  • • An assessment of the recipient’s needs based on:
  • • Baseline measurements
  • • Symptoms
  • • Behavior
  • • Skills
  • • Abilities
  • • Resources
  • • Vulnerabilities
  • • Safety
  • • Clinical summary
  • • Clinical summary, including recommendations and prioritization of needed mental health or other services
  • • Involvement of the recipient and recipient’s family in the assessment and their preferences or referrals to services
  • • Diagnosis on all axes of the current DSM

  • CTSS Requirements
    CTSS requires an annual DA for children up to age 18 (CTSS annual DA exception). For adolescents age 18-21, only an annual adult DA update is required unless the mental health status has changed.

    Interactive Complexity

    Use the Interactive Complexity add-on code (90785) to designate a service with interactive complexity. Report interactive complexity for services when any of the following exist during the visit:

  • • Communication difficulties among participants that complicate care delivery, related to issues such as:
  • • High anxiety
  • • High reactivity
  • • Repeated questions
  • • Disagreement
  • • Caregiver emotions or behaviors that interfere with implementing the treatment plan
  • • Evidence is discovered or discussed, relating to an event that must be reported to a third party. This may include events such as abuse or neglect that require a mandatory report to the state agency
  • • The Mental Health provider overcomes communication barriers:
  • • By using any of the following methods:
  • • Play equipment
  • • Physical devices
  • • An interpreter
  • • A translator
  • • For recipients who:
  • • Are not fluent in the same language as the Mental Health provider
  • • Have not developed or have lost the skills needed to use or understand typical language
  • Authorization

  • • Refer to Authorization for general authorization policy and procedures. Authorization is required to exceed two diagnostic assessment sessions per calendar year
  • • When requesting authorization for services that are to be performed with interactive complexity, include the Interactive Complexity add-on code on the authorization request

  • To request authorization, submit the following:

  • MHCP Authorization Form (DHS-4695) (except when using MN–ITS)
  • • Any past DA’s, or an explanation of why it is not available and any attempts to obtain
  • • Written explanation of why the new DA is needed
  • Billing

  • • Bill a diagnostic assessment (DA) online using MN–ITS 837P
  • • Complete all Diagnostic Assessment (DA) Report Components before billing a DA
  • • Enter the date of service for the DA as the date the written DA report is completed
  • • Enter the treating provider NPI number on each claim line
  • • Add appropriate modifiers for each type and when clinical trainees conduct the assessment

  • If a diagnostic assessment does not result in a diagnosis of mental illness or emotional disturbance, the provider is allowed to provide and bill for the following if performed:

  • • 90887: One Explanation of Findings session
  • • 96101, 96102, 96103: Psychological Testing

  • Do not bill for diagnostic assessment on the same day as:

  • • E/M services provided by the same provider
  • • Psychotherapy services (any type)

  • Use the following table for billing services with date of service on or after January 1, 2013:

    CPT codes for Diagnostic Assessment

    Code

    Modifier

    Brief Description

    Unit

    Limitations

    90791

     

    Standard Diagnostic Assessment

    1 Session

  • • Maximum of four sessions, cumulative (90791 and 90792, all types) per calendar year
  • • A recipient may not receive more than two Brief Diagnostic Assessments in a calendar year
  • • Interactive complexity add-on 90785 may be used with 90791 and 90792
  • • 90792 may be provided by:
  • • Clinical Nurse Specialist-Mental Health (CNS-MH)
  • • Psychiatric Nurse Practitioner (NP)
  • • Psychiatrist
  • • Clinical trainees associated with these mental health professional types
  • • Add modifier HN for services provided by a Clinical Trainee
  • 52

    Brief Diagnostic Assessment

    TG

    Extended Diagnostic Assessment

    TS

    Adult Update Diagnostic Assessment

    90792

     

    Standard Diagnostic Assessment with medical services

    1 Session

    52

    Brief Diagnostic Assessment with medical services

    TG

    Extended Diagnostic Assessment with medical services

    TS

    Adult Update Diagnostic Assessment with medical services

    Teaching hospitals may enter the GC modifier for services performed under the direction of a supervising physician.



    Refer to 2012 Diagnostic Assessment for information about billing services with date of service prior to January 1, 2013.

    Legal References

    Minnesota Rules 9505.0370, 9505.0371, 9505.0372 Mental Health Services

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