Children’s Therapeutic Services and Supports (CTSS)

Revised: August 1, 2024

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization Requirements

· Billing

· Legal References

Overview

CTSS is a flexible package of mental health services for children (includes adolescents and young adults up to age 21) who require varying therapeutic and rehabilitative levels of intervention. CTSS covers services for a diagnosed emotional disturbance or diagnosed mental illness in children that are determined to be medically necessary by a mental health professional. The services are delivered using various treatments and combinations of services designed to reach outcomes identified in the individual treatment plan.

Goals of CTSS are to:

· Restore a child, adolescent, or young adult to an age and developmentally appropriate level of functioning.

· Teach and practice skills which help the child, adolescent, or young adult to cope with mental health symptoms. CTSS is a rehabilitative service which can be used to deliver: psychotherapy or skills training. Psychotherapy treats the underlying mental illness and skills training facilitates psychosocial skill development.

Eligible Providers

CTSS providers are enrolled in Minnesota Health Care Programs (MHCP) and must be certified to provide CTSS mental health rehabilitation services. CTSS providers must be recertified by Minnesota Department of Human Services (DHS) every three years. Certified CTSS programs may utilize the following staff types:

· Mental health professional

· Mental health practitioner

· Clinical trainee

· Mental Health Behavioral Aide (MHBA) Services*

· Mental Health Certified family peer support

* An MHBA is a paraprofessional working under the supervision of mental health professionals (employed by the same CTSS provider or another CTSS agency). An MHBA implements the one-on-one MHBA services identified in a child’s ITP. An MHBA provides MHBA services and meets the requirements of Minnesota Statutes, 245I.04, subdivision 16.

School-based providers

Schools choose from one of the following two CTSS options:

· Contract CTSS – the school chooses to contract mental health services from a CTSS certified community provider

· School CTSS – the school employs mental health staff

IEP evaluation only: refer to Individualized Education Program (IEP) Services or Notification of Intent to bill for Individual Education Plan (IEP) Mental Health Evaluations (DHS-7840) (PDF)

Schools use different billing codes and authorization processes. Review the IEP Billing and Authorization Requirements section of the MHCP Provider Manual for more information.

Recertification

Recertification requires submitting a Children's Therapeutic Services and Supports (CTSS) Provider Application (DHS-3610) (PDF). Recertification will include a site review to examine policies and procedures and clinical documentation of CTSS services. A provider must be certified every three years and meet statutory standards. The commissioner must require corrective action upon determination that a provider fails to meet one or more requirements in law or fails to meet the clinical or administrative standards provided in the application and recertification process. The commissioner must establish a timeline for corrective action compliance, based upon standardized recertification criteria. When an agency fails to comply with corrective action, fails to meet one or more statutory standards, the commissioner will issue a provisional certification until the provider complies with corrective action and statutory standards, or initiate decertification proceedings and notify the provider. The commissioner must use the provider’s certification anniversary date or calendar year end, whichever is greater, as the provider’s recertification date; however, the commissioner may extend a recertification date to sustain services or to stagger recertification site visits across the calendar.

Decertification

Upon the commissioner’s determination that a provider no longer meets the requirements in law or fails to meet the clinical quality standards or administrative standards provided in the application and certification process, the commissioner must require corrective action, medical assistance repayment or decertification of the provider.

Provider Responsibilities

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 member’s and family’s needs, as specified in each member’s individual treatment plan. Mental health professionals and practitioners providing CTSS must:

· Develop an ITP for necessary and appropriate care based on information in the child’s standard diagnostic assessment and the documented input of the family and other authorized caregivers

· Ensure that the member approves of the individual treatment plan unless court orders the members treatment plan under Minnesota Statutes, 253B

· Review the ITP at least every 180 days with the member and the member’s parents or guardians, or primary caregivers

· 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)

· Provide treatment supervision plans for staff according to Minnesota Statutes, 245I.06. A treatment supervisor must be available for urgent consultation as required by the individual client’s needs or the situation

Eligible Members

MHCP members must meet all of the following criteria to be eligible for CTSS:

· Be under 21 years old

· Have a diagnostic assessment, performed by a mental health professional or clinical trainee, that is performed within one year before the initial start of services, that documents:

· A diagnosis of an emotional disturbance for children under 18 years old or mental illness for young adults 18 through 21 years old

· Documents CTSS as medically necessary rehabilitation to address an identified disability or functional impairment, and the member’s needs and goals. (Refer to the diagnostic assessment section in this manual section for more information.) This includes development and rehabilitative services that support a child’s developmental treatment needs.

· Have a completed and signed individual treatment plan that is child-centered, family-driven, and culturally appropriate and:

· Documents specific goals and objectives for CTSS services

· Is approved by the supervising mental health professional and the parent or guardian before service delivery

A member may be determined to be eligible for up to five days of day treatment based on a hospital's medical history and presentation examination of the member before standard diagnostic assessment being completed.

Covered Services

The following services are billable as CTSS:

· Individual and/or family psychotherapy, family psychotherapy, psychotherapy for crisis, and group psychotherapy

· Individual, family, or group skills training provided by a mental health professional, clinical trainee, or mental health practitioner

· Crisis planning

· Mental health behavioral aide services

· Direction of a mental health behavioral aide

· Mental health service plan development

· Children's day treatment

If services are delivered without the child present, document the reason why. All services must be for the benefit of the recipient child, even if they are not present.

Diagnostic Assessment

CTSS services are based on a diagnostic assessment as required in Minnesota Statutes, 245I.10, with the exception of beginning day treatment services for up to five days based on a hospital history and documented symptoms. A provider may review an existing diagnostic assessment or provide one to the client. If a diagnostic assessment is otherwise accurate and indicates a level of need for services but does not specifically recommend CTSS services, the provider should amend the existing DA, and document why CTSS would be appropriate to meet the child’s needs. The diagnostic assessment may identify any of the allowable conditions in the Mental Health Diagnostic Code Ranges as a basis for CTSS, so long as the remaining elements of medical necessity can be demonstrated. This includes autism and related conditions.

Individual Treatment Plan (ITP)

An individual treatment plan (ITP) is a written plan that documents the treatment strategy, the schedule for accomplishing the goals and objectives, and the responsible party for each treatment component as required in Minnesota Statutes, 245I.10. An ITP for CTSS is based on a diagnostic assessment and baseline measurements and approved by a mental health professional. The ITP documents the plan of care and guides treatment interventions and strategies. Development of the ITP includes involvement of the member, member’s family, caregivers or other people, which may include people authorized to consent to mental health services for the member and includes arrangement of treatment and support activities consistent with the member’s cultural and linguistic needs. The ITP focuses on their priority treatment goals and objectives, and the interventions and strategies that will help meet those goals and objectives. The plan must be written in a way in which the person and their family have a clear understanding of the services being offered and specifically how the services will address their concerns. The identified member, and any family or support persons desired, must take part in the process of developing the ITP to make sure the treatment is relevant to the priorities and incorporates the clients’ strengths. Treatment plans must clearly identify medically necessary interventions and be medically supervised by a mental health professional, trainee or mental health practitioner if a service is provided during a primary recreation-oriented time.

Psychotherapy

Psychotherapy, as required in Minnesota Statutes, 256B.0671, subdivision 11, is used to address the child’s underlying mental illness. Family psychotherapy may be provided with or without the child present. Psychotherapy is used to treat an underlying issue while skills are used to provide the tools and address more imminent areas of concern. Most youth will benefit from psychotherapy and skills combined for long-term management and change. CTSS is utilized to deliver comprehensive medically necessary care addressing an identified mental health or emotional disorder. A CTSS provider is responsible for delivering or arranging all medically necessary psychotherapy, with the following exceptions:

· The identified client or their parent or guardian chooses not to receive it

· The provider determines that it is no longer medically necessary (this should be documented with an updated diagnostic assessment)

· A shortage of qualified workforce in the area does not allow for services to be provided.

In each case, the reason should be documented in the member’s file, and the need or availability of services should be reassessed when updating the child’s treatment plan.

Skills Training

Skills training facilitates the acquisition and retention of behavioral, functional, or psychosocial skills that are medically necessary to rehabilitate the child to an age-appropriate developmental trajectory that has been disrupted by a diagnosed mental health disorder. Skills training may also be delivered to help the child or youth to self-monitor, compensate for, cope with, counteract, or replace skill deficits or maladaptive skills acquired during the course of a mental illness. Skills training may be provided by mental health professional, clinical trainee, or mental health practitioner.

Skills training and development for family may be done without the member present if the specific skill taught without child present ties into treatment plan objectives.

A mental health professional, clinical trainee, or mental health practitioner must have taught the psychosocial skill before a mental health behavioral aide may practice that skill with the client.

Crisis Planning

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

· Recognize factors causing a mental health crisis

· Identify behaviors related to the crisis

· Be informed of available resources to resolve the crisis

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

· Actions the family should be prepared to take to resolve or stabilize a crisis

· Acute care

· Crisis placement

· Community resources for follow-up

· Emotional support to the family during crisis

Crisis planning may be developed by a mental health practitioner or clinical trainee and revised as needed. A mental health professional will sign off on the crisis plan after development or revisions through routine supervision of services.

Progress Notes

A progress note describes the services delivered. A progress note must be used to document each occurrence of a mental health service, including skills, that a staff person provides to a member.

CTSS providers must use progress notes to document each occurrence of a mental health service that a staff person provides to a member. A progress note must include the following:

· Type of service

· Date of service

· Session start and stop times

· Service location

· Scope of the service

· Goals and objectives targeted in the session

· Intervention delivered and methods used

· Member’s response or reaction to treatment interventions

· Plan for the next or future sessions including treatment changes to be implemented when interventions are ineffective

· Service modality (group or individual)

· Signature, printed name and credentials of the person who provided the service

· Mental health provider travel documentation requirements

· Significant observations if applicable include the following:

· Current risk factors the member may be experiencing

· Emergency interventions by staff persons

· Consultations with or referrals to other professionals, family or significant others

· Changes in symptoms (physical or mental)

Administering and reporting standardized measures
CTSS providers are able to administer (and bill separately for) standardized functional outcome measures and report resulting individual data as part of functional assessment and outcome evaluation. Instruments currently approved by the Commissioner of Human Services are:

· The Child and Adolescent Service Intensity Instrument (CASII) for persons 6 years old until 21 years old

· The Early Childhood Service Intensity Instrument (ECSII) for children 5 years old or younger

· The Child Behavior Checklist (CBCL)

Timeframes

· Service plan development services are the only CTSS covered services that may be billed before the approval of the ITP. Complete a standard diagnostic assessment or diagnostic assessment update before claiming any CTSS covered services.

· Review and update the ITP every 180 days including member’s treatment progress, new objectives and goals, or if the member has not made progress, changes in CTSS providers approach to treatment

Up to 15 hours of CTSS may be provided within a six-month period to a child with severe emotional disturbance with CTSS listed as part of the discharge plan. The child must be:

· residing in a hospital; or

· residing in a residential treatment facility licensed under Minnesota Rules, parts 2960.0580 to 2960.0690; or

· residing in a psychiatric residential treatment facility under Minnesota Statutes, 256B.0625, subdivision 45a; or

· residing in a regional treatment center or other institutional group setting (including crisis respite, or foster care); or

· participating in a partial hospitalization program

Approval

If able, the member or their guardian may indicate approval by written signature, electronic signature, or documented oral approval. If it is not possible to get approval for an updated treatment plan by the parent or guardian during treatment, services must not be denied solely because of this lack of approval. A mental health professional must make efforts to re-engage the parent or guardian to obtain approval within 30 days of the expiration of the previous treatment plan.

Children’s Day Treatment

Refer to Children’s Day Treatment for policies and documentation standards applicable to this service.

Noncovered Services

The following services are not covered as part of CTSS:

· Service components of CTSS simultaneously provided by more than one provider entity unless prior authorization is obtained

· Treatment by multiple providers within the same agency at the same clock time

· Children's therapeutic services and supports provided in violation of Medical Assistance policy in Minnesota Rules, part 9505.0220

· Mental health behavioral aide services provided by a personal care assistant who is not qualified as a mental health behavioral aide and employed by a certified CTSS provider entity

· Service components of CTSS that are the responsibility of a residential or program license holder, including foster care providers under the terms of a service agreement or administrative rules governing licensure

· Consultation with other providers or service agency staff about the care or progress of a child. This service may be separately billable outside of CTSS as mental health clinical care consultation. Refer to Minnesota Statutes, 256B.0671, subdivision 7.

· For children or adolescents with co-occurring substance use disorders, CTSS services should be directed to restore a child or adolescent to an age-appropriate developmental trajectory that had been disrupted by a psychiatric illness. The child or adolescent may require additional services, covered outside of CTSS, to address the substance use disorder.

· Adjunctive activities that may be offered by a provider entity, but are not otherwise covered by Medical Assistance, include:

· A service that is primarily recreation oriented or that is provided in a setting that is not medically supervised. This includes sports activities, exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips to community activities, and tours. Refer to the Individual Treatment Plan section for medically necessary treatment during these times

· A social or educational service that does not have or cannot reasonably be expected to have a therapeutic outcome related to the client's emotional disturbance

· Prevention or education programs provided to the community

Authorization Requirements

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 (with patient or family member or both)

· Skills training

· Crisis planning

· Mental health behavioral aide (MHBA) services

· Service plan development

· 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

· Up to 24 sessions per calendar year of service plan development

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

Follow these billing guidelines:

· Bill CTSS services using MN–ITS 837P

· Follow NCCI standards

· No interval is required between sessions

· Enter the treating provider NPI number on each claim line

Use the following table for billing services:

Children’s Therapeutic Services and Supports (CTSS) for children under 21 years old
Procedure Code	Modifier	Brief Description	Unit (*Per CPT Time Rule)	Service Limitation
90832	UA	Psychotherapy (with patient or family member or both)	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, refer to Authorization. Psychotherapy (with patient or family member or both) counts toward the 200-hour CTSS authorization threshold (includes biofeedback and E/M with psychotherapy add-on).
90834	UA	Psychotherapy (with patient or family member or both)	45 (38-52*) min.
90837	UA	Psychotherapy (with patient or family member or both)	60 (53+*) min.
Appropriate E/M and 90833	UA	E/M with psychotherapy add-on (with patient or family member or both)	30 (16-37*) min.
Appropriate E/M and 90836	UA	E/M with psychotherapy add-on (with patient or family member or both)	45 (38-52*) min.
Appropriate E/M and 90838	UA	E/M with psychotherapy add-on (with patient or family member or both)	60 (53+*) min.
90875	UA	Individual psychophysiological therapy incorporating biofeedback, with psychotherapy	30 (16-37) min.
90876	UA	Individual psychophysiological therapy incorporating biofeedback, with psychotherapy	45 (38-52) min.
90846	UA	Family psychotherapy without patient present	50 (26+) min.	Calendar year thresholds, refer to Authorization. · 26 sessions of family psychotherapy (including outpatient family psychotherapy) · 10 sessions of multiple family group psychotherapy
90847	UA	Family psychotherapy with patient present	50 (26+) min.
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, refer to Authorization. 52 sessions of group psychotherapy (including outpatient group psychotherapy).
90839	UA	Psychotherapy for crisis	60 (53+*) min.	CNS-MH; LICSW; LMFT; LPCC; LP; NP; psychiatrist; clinical trainee. Does not count toward the 200-hour CTSS authorization threshold.
90840 (add on to 90839)	UA	Psychotherapy for crisis, clinical trainee	30 (16-37) min.	CNS-MH; LICSW; LMFT; LPCC; LP; NP; psychiatrist. Does not count toward the 200-hour CTSS authorization threshold.
H0031	UA	Administering and reporting standardized measures	1 session	Calendar year threshold, refer to Authorization. Administering and reporting standardized measures services count toward the 200-hour CTSS authorization threshold.
H0032	UA	Treatment plan development and review	1 session	Calendar year threshold, refer to Authorization. Up to 24 sessions of service plan development per calendar year Treatment Plan Development and Review services count toward the 200-hour CTSS authorization threshold.
H2012	UA HK	Behavioral Health Day Treatment	1 hour	Refer to Children’s Day Treatment section of the MHCP Provider Manual for service limitation and authorization.
H2012	UA HK U6	Behavioral Health Day Treatment	1 hour
H2014	UA	Skills training and development - individual	15 min.	Only one type of skills training delivered to a member during the same clock time will be reimbursed. Calendar year threshold, refer to Authorization. Skills Training and Development counts toward the 200-hour CTSS authorization threshold.
	UA HQ	Skills training and development - group
	UA HR	Skills training and development - family
H2015	UA	Comp community support services – crisis assistance	15 min.	Calendar year threshold, refer to Authorization. Crisis Assistance counts toward the 200-hour CTSS authorization threshold.
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, refer to Authorization. Mental Health Behavioral Aide (MHBA) services count toward the 200-hour CTSS authorization threshold.
	UA HM	Therapeutic behavioral services – Level II MHBA
	UA HE	Therapeutic behavioral services – direction of MHBA

Legal References

Minnesota Statutes, 245I Mental Health Uniform Service Standards Act
Minnesota Statutes, 256B.0943 CTSS
Minnesota Statutes, 256B.0671 Psychotherapy
Minnesota Rules, 9505.2175 case documentation