Diagnostic Assessment

Revised: December 1, 2023

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Authorizations

· Billing

· Legal References

Overview

The diagnostic assessment (DA) is necessary to determine a member’s eligibility for mental health services through Minnesota Health Care Programs (MHCP). The DA is a written report that documents the clinical and functional face-to-face evaluation of a person’s mental health. The report must include the:

· Nature, severity, and impact of behavioral difficulties

· Functional impairment

· Subjective distress

· Strengths and resources

The provider may perform the DA with or without medical services. Medical services include:

· Prescription of medications

· Reviewing and ordering laboratory services

· Other diagnostic studies

Eligible Providers

Only a mental health professional or a clinical trainee can complete aspects of the diagnostic assessment.

Eligible Members

All MHCP members are eligible for a standard diagnostic assessment.

Covered Services

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

· Identify at least one mental health diagnosis for which the member meets the diagnostic criteria and recommend mental health services to develop the member’s mental health services and treatment plan; or include a finding that the member does not meet the criteria for a mental health disorder.

· Include a face-to-face interview with the member and a written evaluation. Diagnostic assessments may be conducted using telemedicine technology when appropriate.

· Meet the conditions of a standard or brief diagnostic assessment according to Minnesota Statutes 245I, subdivisions 4 - 6

· Document the medical necessity for mental health services in the diagnostic assessment.

Diagnostic assessments completed before the Uniform Service Standards Acts effective date Oct. 17, 2022, are valid for authorizing the member’s treatment and billing for one calendar year after the date of completed assessment.

Standard Diagnostic Assessment

· Providers must conduct a standard DA in the cultural context of the member.

· Providers must gather and document information about the member’s current life situation, include all the components of a standard DA in the report:

· Age

· Current living situation, including housing status and household members

· Status of the basic needs

· Education level and employment status

· Current medications

· Immediate risks to the client's health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotional symptoms

· The member’s perceptions of own condition

· The member’s description of symptom, including the reason for referral

· The client's history of mental health and substance use disorder treatment

· Cultural influences

· Substance use history, if applicable, including

· Amounts and types of substances, frequency and duration, route of administration, periods of abstinence, and circumstances of relapse

· The impacts to functioning when under the influence of substances, including legal interventions.

· If the assessor cannot obtain the information that this paragraph requires without retraumatizing the client or harming the client's willingness to engage in treatment, the assessor must identify which topics will require further assessment during the course of the client's treatment. The assessor must gather and document information related to the following topics:

· The client's relationship with the client's family and other significant personal relationships, including the client's evaluation of the quality of each relationship

· The client's strengths and resources, including the extent and quality of the client's social networks

· Important developmental incidents in the client's life

· Maltreatment, trauma, potential brain injuries, and abuse that the client has suffered

· The client's history of or exposure to alcohol and drug usage and treatment; and

· The client's health history and the client's family health history, including the client's physical, chemical, and mental health history.

· Providers must provide an explanation of how they diagnosed the member using the information from the member’s interview, assessment, psychological testing, and collateral information. Include the member’s needs, risk factors, strengths, and the responsivity factors.

· Providers must consult the member and the member’s family about which services that the member and the family prefer, and must make referrals for the member as to services required by law.

· When completing a standard DA, an assessor must use a recognized diagnostic framework:

· Members who are five years of age or younger: Use the current edition of the DC: 0-5 Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood published by Zero to Three

· Members who are six years of age or older: Use the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association

· Members 18 years of age or older: Use either the CAGE-AID Questionnaire or the criteria in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association to screen and assess the member for a substance use disorder.

· Providers must complete a new standard DA:

· If additional mental health services are needed and the member does not meet the criteria for a brief DA.

· When the member’s mental health condition has changed markedly since the most recent DA

· When a member’s mental health condition does not meet the criteria of the current diagnosis

· When a client member requests

For a member who is already receiving services and has a prior assessment, providers must complete a written update including:

· All significant new or changed information about the member

· Removal of outdated or inaccurate information

· An update about what information has not significantly changed

Providers must discuss the following areas with the member since the member’s last assessment:

· Changes in the member’s life situation

· Functioning

· Presenting problems (clinical issues the member is experiencing)

· Progress with achieving treatment goals

If the new diagnostic assessment refers to material gathered and analyzed in a prior assessment, the provider should clearly link to the earlier record or add it to the current record.

Brief Diagnostic Assessment

· Providers must include all of the components of the brief DA in the report:

· Age

· Description of symptoms, including the reason for the referral

· History of mental health treatment

· Cultural influences

· Mental status examination

· Based on the initial components of the brief assessment, the assessor must develop a provisional diagnostic formulation about the member. The assessor may use the provisional diagnostic formulation to address the client's immediate needs and presenting problems.

· A mental health professional or clinical trainee may use treatment sessions with the member authorized by a brief diagnostic assessment to gather additional information to complete the standard diagnostic assessment if the number of sessions will exceed coverage limits.

· Based on the member’s needs after a brief DA is completed, a provider may provide any combination of psychotherapy sessions, group psychotherapy sessions, family psychotherapy sessions, and family psychoeducation sessions not to exceed 10 sessions within a 12-month period without prior authorization for any new or existing client who is projected to need fewer than 10 sessions during the next 12 months.

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 members 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

Exceptions

Providers must use the member’s DA to determine eligibility for mental health services, except as provided in this section:

· The following services can be provided before completing the member’s initial DA:

· Explanation of findings

· Neuropsychological testing, neuropsychological assessment, and psychological testing

· Up to three sessions of any combination of psychotherapy sessions, family psychotherapy sessions, and family psychoeducation sessions

· Crisis assessment and services according to Minnesota Statutes 256B.0624

· 10 days of intensive residential treatment services according to the assessment and treatment planning standards in Minnesota Statutes 245.23, subdivision 7

· Based on the member’s needs that a hospital medical history and presentation examination identifies, a provider may provide:

· Any combination of psychotherapy sessions, group psychotherapy sessions, family psychotherapy sessions, and family psychoeducation sessions not to exceed 10 sessions within a 12-month period without prior authorization for any new or existing client who is projected to need fewer than 10 sessions during the next 12 months

· Up to five days of day treatment services or partial hospitalization

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) (PDF) (except when using MN–ITS)

· Any past DAs, or an explanation of why it is not available and any attempts to obtain

· Written explanation of why the new DA is needed

Billing

Follow these guidelines for billing:

· Bill a diagnostic assessment (DA) online using MN-ITS 837P

· Complete all DA report components before billing

· 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:

· One Explanation of Findings session: code 90887

· Psychological Testing: codes 96130, 96131, 96136, 96137, 96138, 96139, 96146

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

· Evaluation and Management (E/M) services provided by the same provider

· Services (any type)

Use the following table for billing services:

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 member 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
90792		Standard diagnostic assessment with medical services	1 session
	52	Brief diagnostic assessment with medical services
Teaching hospitals may enter the GC modifier for services performed under the direction of a supervising physician.

Legal References

Minnesota Statutes 245I.10
Minnesota Statute 245.461 Diagnostic codes list