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| A diagnostic assessment 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 |
| • 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 |
| • 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 |
| 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: |
| • Clinical Nurse Specialist-Mental Health (CNS-MH) |
| • Psychiatric Nurse Practitioner (NP) |
| All MHCP recipients are eligible for diagnostic assessment. |
| To be eligible for MHCP payment, a diagnostic assessment must: |
| • Meet the conditions of the selected diagnostic assessment type |
| • 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. |
| The four types of Diagnostic Assessments (DA) are: |
| • 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: |
| • 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) |
| • Contextual non-personal factors contributing to the recipient’s presenting concerns |
| • General physical health and relationship to recipient’s culture |
| • Recipient’s description of symptoms (including reason for referral) |
| • 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: |
| • 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: |
| • 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 |
| • Cultural considerations |
| • Appointments may be conducted outside the office, with or without the child present, for face-to-face consultation and information gathering with: |
| • 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: |
| • Physical aspects, including: |
| • Vocalization and speech production, including expressive and receptive language |
| • Affect and mood, including: |
| • Modulation of aggression |
| • 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 |
| • 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 |
| • Social support network members |
| • Recovery support resource representatives |
| • 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 |
| • An assessment of the recipient’s needs based on: |
| • 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. |
| 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: |
| • 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: |
| • 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 |
| • 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: |
| • 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 |
| • Bill a diagnostic assessment (DA) online using MN–ITS 837P |
| • The date of service for the DA is 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: |
| 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: |
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| CPT codes for Diagnostic Assessment
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| Code
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Modifier
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Brief Description
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Unit
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Limitations
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| 90791
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Standard Diagnostic Assessment
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1 Session
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l Maximum of four sessions, cumulative (90791 and 90792, all types) per calendar year
l A recipient may not receive more than two Brief Diagnostic Assessments in a calendar year
l Interactive complexity add-on 90785 may be used with 90791 and 90792
l 90792 may be provided by:
l Clinical Nurse Specialist-Mental Health (CNS-MH)
l Psychiatric Nurse Practitioner (NP)
l Psychiatrist
l Clinical trainees associated with these mental health professional types
l Add modifier HN for services provided by a Clinical Trainee
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| 52
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Brief Diagnostic Assessment
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| TG
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Extended Diagnostic Assessment
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| TS
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Adult Update Diagnostic Assessment
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| 90792
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Standard Diagnostic Assessment with medical services
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1 Session
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| 52
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Brief Diagnostic Assessment with medical services
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| TG
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Extended Diagnostic Assessment with medical services
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| TS
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Adult Update Diagnostic Assessment with medical services
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| Teaching hospitals may enter the GC modifier for services performed under the direction of a supervising physician.
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