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Children’s Therapeutic Services and Supports (CTSS)

Revised: 05-28-2013

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Non-Covered Services
  • Billing
  • Authorization
  • Legal Reference
  • Overview

    CTSS is a flexible package of mental health services for children who require varying therapeutic and rehabilitative levels of intervention. CTSS addresses the conditions of emotional disturbance that impair and interfere with an individual’s ability to function independently. For children with emotional disturbances, rehabilitation means that services are provided to restore the child to a level of functioning that they either had or would have achieved if normal development had not been impaired by a mental health disorder. CTSS services are time-limited interventions that are delivered using various treatment modalities and combinations of services designed to reach measurable treatment outcomes identified in an individual treatment plan (ITP).

    Eligible Providers

    CTSS providers include CTSS certified agencies and their qualified employees eligible to enroll as MHCP providers.

    The following entities may request MHCP certification as CTSS providers:

  • • County-operated entities
  • • Community Mental Health Centers (CMHCs)
  • • Hospital-based providers
  • • Indian health services/638 facilities
  • • Non-county mental health rehabilitative providers
  • • School districts

  • Provider Responsibilities

    A certified CTSS provider must ensure that caseload size permits the provider to deliver services to both recipients with severe, complex needs and recipients with less intensive needs. The provider’s caseload size should reasonably enable the provider to play an active role in service planning, monitoring, and delivering services to meet the recipient’s and family’s needs, as specified in each recipient’s individual treatment plan. Mental health professionals/practitioners providing CTSS must:

  • • Develop an ITP for necessary and appropriate care based on information in the child’s standard or extended diagnostic assessment and the documented input of the family and other authorized caregivers
  • • Sign the ITP (the child/legal guardian and mental health professional or clinical supervisor of the practitioner must sign the ITP before implementing service)
  • • Review the ITP at least every 90 days with the recipient and the recipient’s parents/guardians
  • • Ensure that the services provided are designed to meet specific mental health needs of the child and the child’s family according to the child’s ITP
  • • Coordinate CTSS services
  • • Work with other health care providers (including multiple agencies, if for example, the child has an additional diagnosis of developmental disability, substance abuse, or physical condition requiring regular medical care)

  • Mental Health Professionals

    LP
    LPCC

    LICSW

    LMFT

    Psychiatrist

    CNS

    NP

    Mental Health Practitioner

    Mental health practitioners may provide the following services under CTSS:

  • • Skills training
  • • Crisis assistance
  • • Direction of mental health behavioral aides (MHBA)

  • Mental health practitioners who are qualified as clinical trainees may also provide psychotherapy.

    Requirements

    Refer to General MHCP Non-Enrollable Mental Health Provider Requirements (see the Non-Enrollable Providers Training & Continuing Education Requirements section) for additional practitioner requirements.

    CTSS Certification

    Providers must be certified prior to delivering CTSS services. Certification involves approval and acceptance of the provider agency’s application based on whether the agency meets the statutory standards. Initial certification may be for one to three years. Prior to applying for certification, potential CTSS agency providers must attend the following trainings:

  • • CTSS Administrative
  • • CTSS Clinical

  • Registration information, training dates and materials can be found under CTSS Applicant Provider Information Session on the Children’s Mental Health-Training Information page.

    The following three documents were developed for the CTSS application and certification process:

  • Children’s Therapeutic Services and Supports Provider Certification Process (DHS-3622)
  • Children’s Therapeutic Services and Supports Provider Entity Application Guideline (DHS-3623)
  • Children’s Therapeutic Services and Supports Provider Entity Primary Certification Application (DHS-3610)

  • To be certified, providers must be able to deliver the core services of:

  • • Psychotherapy
  • • Skills training
  • • Crisis assistance

  • In addition, providers may be certified to provide:

  • • CTSS day treatment
  • • Therapeutic preschool services
  • • Mental health behavioral aide service

  • Initial certification may be limited to certification for core services. Additional service packages may be added later by submitting the CTSS addendum application.

    Schools seeking certification must follow criteria on the Children’s Therapeutic Services and Supports Overview for Schools and School Districts (DHS-4982B) and the IEP Technical Assistance Guide (DHS-4439).

    Recertification

    Recertification requires reviewing Recertification Review Process (DHS-4978) and submitting a Recertification Application (DHS-4979). Recertification will include a site review to examine policies and procedures and clinical documentation of CTSS services.

    Decertification

    The commissioner may intervene at any time and decertify providers with cause. The decertification is subject to appeal to the state.

    Eligible Recipients

    To be eligible for CTSS, recipients must have an individual treatment plan (ITP) that clearly documents the necessity for the type of mental health service requested, including intensity of treatment and medical necessity. Recipients must also be:

  • • Children under age 18 diagnosed with an Emotional Disturbance (ED) or meet Severe Emotional Disturbance (SED) criteria
  • • Young adults ages 18 through 20 diagnosed with Mental Illness (MI) or meet Serious or Persistent Mental Illness (SPMI) criteria

  • The diagnostic assessment used to establish eligibility for CTSS must be done by a mental health professional or qualified mental health practitioner within 180 days before CTSS services begin.

    In addition to the general MHCP requirements for a Diagnostic Assessment (DA), CTSS requires that the DA:

  • • Include current diagnoses on all five axes of the DSM-IV
  • • Document CTSS as medically necessary rehabilitation to address an identified disability or functional impairment, and related needs
  • • Be used in the development of the recipient’s ITP goals and objectives
  • • Be completed annually until age 18 or updated annually for recipients age 18 and 21, unless a recipient’s mental health condition has changed markedly since the most recent diagnostic assessment. A recipient with autism spectrum disorder or pervasive developmental disorder may receive a diagnostic assessment once every three years, at the request of the parent or guardian, if a mental health professional agrees there has been little change in the condition and that an annual assessment is not necessary.
  • Covered Services

    CTSS providers must provide or ensure the following services, as prescribed in the child’s ITP:

  • Psychotherapy - with patient and/or family member, family, and group
  • Skills training - individual, family, or group
  • Crisis assistance
  • MHBA services, including direction of a mental health behavioral aide

  • Psychotherapy and skills training service components may be combined to constitute therapeutic programs, including day treatment and therapeutic preschool programs. These programs have specific recipient and provider eligibility requirements.

    Psychotherapy

    Refer to Psychotherapy for additional information about this service.

    Skills Training

    Skills training is medically necessary when the child has lost behavioral skills or failed to develop behavioral skills compared to others of similar age as a result of their diagnosed mental health disorder. Skills training may also be delivered to help the youth to self-monitor, compensate for, cope with, counteract, or replace skills deficits or maladaptive skills acquired during the course of a psychiatric illness. Unlike a thought, feeling or perception, a skill is observable by others. It is an activity that must be practiced in order to be mastered and maintained. There are right ways and wrong ways to perform the skill. Typically, a skill is performed for a reason and a skill can be generalized and adapted to many different situations.

    Skills training is subject to the following requirements:

  • • A mental health professional or a mental health practitioner must provide skills training
  • • The child must always be present during skills training. However, a brief absence of the child, for no more than ten percent of the session, may be allowed to redirect or instruct family members
  • • Skills training delivered to children or their families must be targeted to the specific deficits or maladaptations of the child's mental health disorder and must be prescribed in the child's individual treatment plan
  • • Skills training delivered to the child's family must teach skills needed by parents to enhance the child's skill development and to help the child use the skills and develop or maintain a home environment that supports the child's ongoing use of the skills
  • • Group skills training may be provided to multiple recipients who, because of the nature of their emotional, behavioral, or social dysfunction, can derive mutual benefit from interaction in a group setting, which must be staffed as follows:
  • • One professional or one practitioner must work with a group of four to eight recipients
  • • Two professionals or two practitioners, or one professional plus one practitioner must work with a group of nine to 12 recipients

  • Crisis Assistance

    Crisis assistance is for the child, the child’s family, and all providers of services to the child to:

  • • Recognize factors precipitating a mental health crisis
  • • Identify behaviors related to the crisis
  • • Be informed of available resources to resolve the crisis

  • Crisis assistance requires the development of a plan that addresses prevention and intervention strategies in a potential crisis, including plans for:

  • • Arranging admission to acute care hospital inpatient treatment
  • • Crisis placement
  • • Community resources for follow-up
  • • Emotional support to the family during crisis

  • Mental Health Behavioral Aide (MHBA)

    A MHBA is a paraprofessional working under the clinical supervision of mental health professionals (employed by the same CTSS provider or another CTSS agency). A MHBA implements the 1:1 MHBA services identified in a child’s ITP and individual behavior plan (IBP). A MHBA provides either MHBA services or is part of the multidisciplinary staff for therapeutic preschool programs.

    Requirements

  • • MHBA requirements are in the General MHCP Non-Enrollable Mental Health Provider Requirements table in the CTSS section. This section also includes pre-service and continuing education requirements.
  • MHBA Clinical Supervision: In addition to clinical supervision requirements CTSS entities that elect to provide MHBA services also must provide direction for MHBAs.

  • Services
    MHBA services are designed to provide medically necessary services to improve the functioning of the child in the progressive use of developmentally appropriate psychosocial skills. Activities involve working directly with the child, child-peer groupings, or child-family groupings to practice, repeat, reintroduce, and master the skills previously taught by a professional or practitioner including:

  • • providing cues or prompts in skill-building peer-to-peer or parent-child interactions so that the child progressively recognizes and responds to the cues independently
  • • performing as a practice partner or role-play partner
  • • reinforcing the child's accomplishments
  • • generalizing skill-building activities in the child's multiple natural settings
  • • assigning further practice activities
  • • intervening as necessary to redirect the child's target behavior and to de-escalate behavior that puts the child or other person at risk of injury.

  • All services provided by a MHBA must be identified in an individual behavior plan (IBP). The IBP must be developed by the supervising mental health professional or by a mental health practitioner under the supervision of the mental health professional.

    The child’s ITP must:

  • • Identify the need for MHBA services
  • • Determine the scope, duration, and frequency of services required for the child and child’s family

  • Before an MHBA provides services, the mental health professionals must approve the IBP that details the:

  • • Instructions of the services the MHBA is expected to provide
  • • Time allocated to each service
  • • Methods of documenting the child’s behavior
  • • Methods of monitoring the progress of the child in reaching objectives
  • • Goals to increase or decrease targeted behavior as identified in the ITP

  • In accordance with IBP the MHBA must:

  • • Implement activities in the child’s IBP
  • • Document the delivery of services and progress on objectives in progress notes

  • Direction of the MHBA
    Direction refers to the activities of mental health professionals, or mental health practitioners under the supervision of a mental health professional, to guide the work of the MHBA. Direction of the MHBA is a covered service.

    The mental health professional or mental health practitioner giving direction must begin with the goals on the individualized treatment plan, and instruct the mental health behavioral aide on how to construct therapeutic activities and interventions that will lead to goal attainment. The professional or practitioner giving direction must also instruct the mental health behavioral aide about the recipient's diagnosis, functional status, and other characteristics that are likely to affect service delivery. Direction must also include determining that the mental health behavioral aide has the skills to interact with the recipient and the recipient's family in ways that convey personal and cultural respect and that the aide actively solicits information relevant to treatment from the family. The aide must be able to clearly explain the activities the aide is doing with the recipient and the activities' relationship to treatment goals. Direction is more didactic than is supervision and requires the professional or practitioner providing it to continuously evaluate the mental health behavioral aide's ability to carry out the activities of the individualized treatment plan and the individualized behavior plan. When providing direction, the professional or practitioner must:

  • • review progress notes prepared by the mental health behavioral aide for accuracy and consistency with diagnostic assessment, treatment plan, and behavior goals and the professional or practitioner must approve and sign the progress notes;
  • • identify changes in treatment strategies, revise the individual behavior plan, and communicate treatment instructions and methodologies as appropriate to ensure that treatment is implemented correctly;
  • • demonstrate family-friendly behaviors that support healthy collaboration among the child, the child's family, and providers as treatment is planned and implemented;
  • • ensure that the mental health behavioral aide is able to effectively communicate with the child, the child's family, and the provider; record the results of any evaluation and corrective actions taken to modify the work of the mental health behavioral aide;

  • Professional and Practitioner responsibilities in the direction of MHBAs includes all the following:
  • • A clinical supervision plan for the MHBA approved by the responsible mental health professional
  • • Ongoing on-site observation by a mental health professional or practitioner for at least one total hour every forty hours of service provided to each child
  • • Immediate accessibility of the professional or practitioner to the MHBA during service provision
  • • Reviewing progress notes prepared by MHBA for accuracy and consistency with diagnostic assessment, treatment plan and behavior goals. Progress notes must be approved and signed by mental health professionals or mental health practitioners
  • • Identifying changes in treatment strategies, revise the IBP and communicate treatment instructions and methodologies, as appropriate, to ensure that treatment is implemented correctly
  • • Demonstrating family friendly behaviors that support healthy collaboration among child, child’s family and providers as treatment is planned and implemented
  • • Ensuring that MHBAs are able to effectively communicate with the child, child’s family and the provider
  • • Recording the results of any evaluation and corrective actions taken to modify the work of MHBAs

  • Additional direction may be provided if a MHBA requires more frequent instruction to carry out the therapeutic activities identified in the ITP and IBP.

    Direction of MHBA is not counted toward CTSS threshold.

    Children’s Day Treatment

    Refer to Children’s Day Treatment for additional information about this service.

    Therapeutic Preschool Program

    The intent of a therapeutic preschool program is to provide early intervention in a licensed, structured day program that provides mental health services by a multidisciplinary staff under the clinical supervision of a mental health professional.

    Early intervention allows the provider to:

  • • Identify the needs and strengths of the child and family
  • • Assist in focusing on education and training goals of family/caregivers, for them to develop skills and strategies in reducing and resolving the symptomology of the child’s emotional disturbance

  • The therapeutic preschool program is for children who:

  • • Are eligible for MA
  • • Are at least age 33 months
  • • Have not yet attended the first day of kindergarten
  • • Have a diagnosis of ED

  • The program structure for the therapeutic preschool program requires that the entity makes the therapeutic preschool program available two hours per day, five days per week, and 12 months of each calendar year.(MHCP payment is limited to two hours per day per recipient)

    The two hours may be divided into flexible time segments according to the recipient’s needs, as defined in the ITP:

    Non-Covered Services

    CTSS does not cover services that are:

  • • The responsibility of a residential or program license holder, including foster care
  • • In violation of medical assistance policy
  • • Treatment by multiple providers within the same agency at the same clock time
  • • MHBA services provided by a personal care assistant who is not qualified as a MHBA and employed by a certified CTSS provider entity
  • • Primarily recreation oriented or provided in a setting that is not medically supervised (such as sports activities, exercise groups, craft hours, leisure time, social hours, meal or snack time, trips to community activities, and tours)
  • • A social or educational service that does not have or cannot reasonably be expected to have a therapeutic outcome related to the child’s emotional disturbance
  • • Consultation with other providers or service agency staff about the care or progress of a child
  • • Prevention or education programs provided to the community
  • • Treatment for recipients with primary diagnoses of alcohol or other drug abuse

  • Limitations

    CTSS are provided primarily in the child’s residence, but may also be provided in the child’s school, the home of a relative or natural parent, a recreational setting or the child’s day care.

    Up to 15 hours of CTSS may also be provided when the service components of CTSS are identified in the discharge plan and are provided within a 6-months time period if the child participates in a partial hospitalization program or resides in one of the following:

  • • Hospital
  • • Group home
  • • Residential treatment facility or center
  • • Other institutional group setting

  • Authorization

    Refer to Authorization for general authorization policy and procedures. For CTSS services authorization is required to exceed:

  • • 200 cumulative hours per calendar year for any combination of:
  • • Psychotherapy
  • • Skills training
  • • Crisis assistance
  • • Therapeutic components of preschool program
  • • Mental Health Behavioral Aide (MHBA) services
  • • 52 cumulative sessions per calendar year of group psychotherapy, including outpatient group psychotherapy services
  • • 26 cumulative sessions per calendar year of family psychotherapy, including outpatient family psychotherapy services
  • • 10 cumulative sessions per calendar year of multiple family group psychotherapy

  • Children’s Day Treatment hours are not included in the 200 hour threshold. Refer to Children’s Day Treatment for additional authorization criteria.

    When requesting authorization for services that are to be performed with interactive complexity, include the Interactive Complexity add-on code on the authorization request.

    Billing

  • • Bill CTSS services using MN–ITS 837P (PDF)
  • • Follow NCCI standards
  • • There are no spacing requirements between sessions
  • • Enter the treating provider NPI number on each claim line
  • • County Contracted Mental Health Rehabilitation providers must contact MHCP to verify that their profile allows for billing services outside the CTSS benefit package

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

    Children’s Therapeutic Services and Supports (CTSS) for Children under age 21

    Proc Code

    Modifier

    Brief Description

    Unit
    (*Per CPT Time Rule)

    Service Limitation

    90832

    UA

    Psychotherapy (with patient and/or family member)

    30 (16-37*) min

    Interactive complexity add-on code (90785) may be used with:

  • • Psychotherapy (90832, 90834 or 90837)
  • • E/M with psychotherapy add-on codes (90833, 90836, 90838)

  • Use the UA modifier on Interactive Complexity add-on codes when reporting with CTSS services.

    E/M with Psychotherapy add-on limited to:

  • • Clinical Nurse Specialist-Mental Health (CNS-MH)
  • • Psychiatric Nurse Practitioner (NP)
  • • Psychiatrist

  • Calendar year threshold, see Authorization - Psychotherapy (with patient and/or family member) counts toward the 200 hour CTSS limit (includes biofeedback and E/M with psychotherapy add-on).

    90834

    UA

    Psychotherapy (with patient and/or family member)

    45 (38-52*) min

    90837

    UA

    Psychotherapy (with patient and/or family member)

    60 (53+*) min

    Appropriate E/M and 90833

    UA

    E/M with Psychotherapy add-on (with patient and/or family member)

    30 (16-37*) min

    Appropriate E/M and 90836

    UA

    E/M with Psychotherapy add-on (with patient and/or family member)

    45 (38-52*) min

    Appropriate E/M and 90838

    UA

    E/M with Psychotherapy add-on (with patient and/or family member)

    60 (53+*) min

    90875

    UA

    Individual psychophysiological therapy incorporating biofeedback, with psychotherapy

    30 (16-37)

    90876

    UA

    Individual psychophysiological therapy incorporating biofeedback, with psychotherapy

    45 (38-52) min

    90846

    UA

    Family Psychotherapy without patient present

    1 Session

    Calendar year thresholds, see Authorization:

  • • 26 sessions of family psychotherapy(including outpatient family psychotherapy)
  • • 10 sessions of multiple family group psychotherapy
  • 90847

    UA

    Family Psychotherapy with patient present

    1 Session

    90849

    UA

    Multiple Family Group Psychotherapy

    1 Session

    90853

    UA

    Group Psychotherapy

    1 Session

    Interactive complexity add-on code (90785) may be used with 90853.

    Calendar year threshold, see Authorization - 52 sessions of group psychotherapy (including outpatient group psychotherapy).

    H2014

    UA

    Skills Training & Development - Individual

    15 min

    Only one type of skills training delivered to a recipient during the same clock time will be reimbursed.

    Calendar year threshold, see Authorization - Skills Training & Development counts toward the 200 hour CTSS limit.

    UA HQ

    Skills Training & Development - Group

    UA HR

    Skills Training & Development - Family

    H2015

    UA

    Comp Community Support Services – Crisis Assistance

    15 min

    Calendar year threshold, see Authorization - The following count toward the 200 hour CTSS limit:

  • • Crisis Assistance
  • • Therapeutic Components of Preschool Program
  • H2012

    UA

    Behavioral Health Day Treatment – Therapeutic Components of Preschool Program

    60 min

    H2019

    UA

    Therapeutic Behavioral Services – Level I MHBA

    15 min

    Level I and Level II MHBA services cannot be delivered at same clock time.

    Calendar year threshold, see Authorization - Mental Health Behavioral Aide (MHBA) services count toward the 200 hour CTSS limit.

    UA HM

    Therapeutic Behavioral Services – Level IIMHBA

    UA HE

    Therapeutic Behavioral Services – Direction of MHBA


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

    Legal Reference

    MS 256B.0943 (CTSS)
    MN Rules 9535.4068
    (continuing education for practitioner and MHBA)
    MN Rules 9503.0015
    , A (Definition of Day Program)

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