Appendix B: Scenarios

Transcription

1 Appendix B: Scenarios Magellan s Mixed Services Guidelines provide direction in distinguishing payer/clinical responsibility for cases that may fall into the area between Behavioral Health responsibility and Medical/Surgical responsibility. Determination of fiscal responsibility can best be determined by the use of the Magellan Mixed Services Guidelines (ICD-10-CM, CPT service, guideline grid, and clinical scenarios) in their entirety. Users are encouraged to have familiarity with all four parts of the complete mixed services protocol. These protocols represent Magellan s position in making claims determinations. We recognize that the protocols, if not adopted in their entirety by client organizations, can act as the template for negotiating a customized Mixed Service Guidelines protocols. The following case scenarios highlight examples of situations in which the Magellan Mixed Services Guidelines have been applied to common clinical and administrative situations. These case scenarios are not meant to be all-inclusive, but are representative of the most common areas that need to be discussed at the implementation of new contracts and referred to as necessary when making determinations about covered services. Clinical Scenario Provider Primary ADHD: Diagnosis or treatment of ADHD (e.g., Pediatrics, Neurology, Family Practice) Type of Service All levels of care Diagnosis or treatment of ADHD All levels of care Autism Spectrum Disorders (ASD)/Pervasive Developmental Disorders (PDD): Diagnosis of ASD/PDD Evaluation : Treatment of ASD/PDD For example: Physical Therapy, Occupational Therapy, Speech Therapy Treatment of ASD/PDD For example: Applied Behavior Analysis; Behavior Modification Program Financial responsibility Plan or Plan or, or local educational district via an Individualized Education Plan (IEP) Behavioral Health Plan if the Magellan autism product is in effect

2 Primary diagnoses e.g., ADHD, depression (secondary of ASD/PDD) Ambulance: party receiving the patient is responsible Transport for assessment or treatment Transport for ordered or assessment or treatment ordered Transport for assessment or ordered or treatment ordered Neuroimaging: Patient in psychiatric hospital bed Attending: for primary psychiatric. Imaging Studies as part of workup for Comorbid Dx- Consult: see Consultations below. IP Consultation: Consultation by Psychiatrist for patient with a attending and primary Dx Consultation by provider for patient with a attending and primary Dx Chronic Pain: Pain Management Program Psychotherapy (individual or group) as part of Pain Management Program but billed outside of per diem and associated with medical issues Psychotherapy as part of pain mgmt program but billed outside of per diem and associated with diagnoses Pain Disorder Associated with psychological factors not ASD/PDD Page 2 of 7 ordered Transport to Transport to Plan or Transport to Consult: Attending: Consult: Attending: Medical: Neurologist, Anesthesiologist, etc. Medical Consulting Diagnosis as Secondary Diagnosis Consult Dx = Facility Bill Dx = Consult Dx = Dx Facility Dx = (e.g. back pain) Separate billing for radiological services received for patient on units. Consultation Consultation IP or OP Pain clinic Psychotherapy associated with medical issues Psychotherapy Plan or for consult Plan or for consult and lab Plan or Plan or Cognitive disorders: Dementia, Delirium, Amnesia, Cognitive Disorders NOS Dementia Dx & Tx Plan or

3 Page 3 of 7 Dementia Dementia Consult: Consultation Attending: Dementia presenting with behavioral changes / Dementia presenting with behavioral changes Delirium Consult: e.g., or Neurology Attending (Neurology, IM etc) F01.51 F02.81 F03.91 or Neurology Consulting Dx F05 R41.0 Psychiatric assessment & Tx, assessment of depression or delusions by a psychiatrist or a neuropsycholog ist; treatment by a psychiatrist and/or Neurological assessment & Consult Medical Plan or for neurological and medical work-up Plan or Delirium Delirium Amnesia Amnesia Amnesia Depot Psychotropic Injections: Provider administers an injection of Haldol Decanoate, Prolixin Decanoate, or Risperdal Consta, etc. Consult: Attending Consult: Attending (Neurology, IM etc) Consult: Attending F05 R41.0 F05 R41.0 F04 R41.3 R41.1 R41.2 F44.0 F19.96 F13.26 F13.96 F19.16 F19.26 Psychiatric assessment & Tx Medical consult Medical Psychiatric assessment and Tx Medical consult Plan or Plan or Plan or For 96372: Behavioral Health Plan or or Plan or, depending upon the benefit structure 96372* Plan or

4 Page 4 of 7 * This code is used to describe the infusion or injection procedure only. The supply of the specific drug(s) is separately reported to the carrier with an appropriate CPT or HCPCS code. Magellan is not responsible for payment for the drug, just the administration of the drug. Detoxification: Medical detoxification with serious medical complications (e.g., end-organ disease, DT's) Medical Detoxification Eating Disorders: Patient with eating disorder admitted for stabilization of medical complications by contract or Medical -- i.e., liver failure, DT s. (Watch for mislabeling as simple withdrawal which can be a covered Dx, but patient was in ICU) Simple withdrawal (e.g., cardiac arrhythmia or malnutrition, or dehydration) OP nutritional services with associated medical diagnoses Medical monitoring for medical condition of patient with eating disorder Psychiatric rehabilitation and treatment Feeding disorders (e.g., serious nutrition/hydration/electrolyte/ cardiac problems) ECT: ECT and all associated services (i.e. anesthesia, recovery room) IP IP or Ambulatory Plan or Plan or Plan or Consult: with associated medical diagnoses Plan or Consult: Attending: Consult Dx: (e.g. histrionic PD, Chronic Factitious Illness with Physical ) Med Dx: dehydration consult for consult services only ( pays IP stay) Emergency Room: ER without a subsequent admission is responsibility of Plan except for the consultation fees

5 . Work-up is to differentiate medical and the workup is negative for a physical condition in a person with a known Dx (e.g., shortness of breath and chest pain in a patient with Panic Disorder) Consult: Attending Consult: Attending Consult: Attending Work up is for distinguishing medical pathology, but Dx is given as default (e.g., R/O Anxiety Disorder or Anxiety Disorder). Primary is medical (.e.g., asthma) or physical (e.g., shortness of breath and chest pain) Secondary from consultant is (e.g., comorbid anxiety in a patient with asthma or Panic Disorder in a patient with Schizophrenia). (e.g., panic attack with shortness of breath and chest pain) (e.g., R/O pulmonary embolus or myocardial infarction) with known secondary (e.g., Panic Disorder) Page 5 of 7 Plan or consultation Consult ER Service. consultation for consult only for the consult only for consult only

6 Presentation with acute psychiatric Head Injury: Head injury resulting in neurological damage with personality and behavioral changes Page 6 of 7 or (Where there are diagnostic tests not typically considered psychiatric, consider discussion between Behavioral Health plan and plan or ) Neurological assessment or Rehab (IP, Res or OP) Plan or Head injury resulting in neurological damage with personality and behavioral changes Consult: Attending Neuropsychological testing / Psychological testing: Testing ordered to rule out or Attending measure neuropathology (Neurologist, Neurosurgeon, Pediatrician) Testing done by (Neuropsychologist) Testing ordered to clarify Testing ordered for defining learning disorders/ IQ ; Dx is secondary, per Consult assessment and/or services Testing (CPT through 96120) (Psychologist) Testing : CPT ; if , only if allowed by benefits or (Pediatricians) or Neurological Testing (CPT 96110, 96111, 96116) for consult and services Plan or Note: Educational testing is usually an excluded benefit for health plans and CMS. Testing ordered for evaluating Pervasive Developmental/Autism Spectrum Disorders (Psychologist) Testing : CPT ; if , only if allowed by benefits Educational testing may be provided by school system for children between 3 and 18 years old. if the is a covered

7 Testing ordered for evaluating Pervasive Developmental/Autism Spectrum Disorders Self-Inflicted Harm: Serious injury or overdose requiring medical intervention and assessment Serious injury or overdose requiring medical intervention and assessment Serious injury or overdose requiring medical intervention and assessment Urgent Clinic (Pediatrician, Developmental Pediatrician) Consult: Attending Consult: Attending Page 7 of 7 Testing Plan or (Medical Trauma) (Medical trauma) with Consult Dx as secondary from Consultant (Medical trauma) consultation Plan or for consult Plan or for consult Plan Consult: for consult