Covered and Noncovered Services : Covered Services and Requirements

Behavior Identification Assessment and Plan of Care Development

ForwardHealth covers clinical assessment activities used to identify target behaviors and to develop a plan of care (such as, treatment plan, protocol) for the member under CPT procedure code 97151 (Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or other qualified healthcare professional's time face-to-face with patient and/or guardian[s]/caregiver[s] administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan). Covered assessment activities include:

• Administration of assessments
• Discussion of findings and recommendations
• Analyzing data
• Scoring and interpreting assessments
• Preparing the report/POC

These assessment activities must be conducted by licensed supervisors. Behavior identification assessment services generally do not require PA. ForwardHealth covers up to 96 units/24 hours of behavior identification assessment services within a calendar year without PA. This service includes a combination of face-to-face and non-face-to-face activities. Providers conducting behavior identification assessments should spend at least half of the assessment time in a face-to-face setting with the member.

If more non-face-to-face time is needed, providers must document the unique clinical circumstances that justify the additional non-face-to-face time relative to the face-to-face assessment services. Providers are required to submit a Prior Authorization Amendment Request for additional units beyond 96 units/24hours.

Documentation Requirements

In order for behavior identification assessment to be reimbursable, providers are required to document all of the following:

• DOS
• Length of the session, including time in and out
• Mode of delivery (for example, in-person or telehealth) (Note: Telehealth requirements are available.)
• Names of staff and individuals present
• Renderer's signature and signature date

Providers must also document the specific assessment activities that occurred, which must include one or more of the following:

• Assessments administered, scored and interpreted
• Face to face time with member and family
• Data analyzed
• Records reviewed
• Development of plan of care
• If updated, copy of plan of care signed and dated by the licensed supervisor and parent or guardian.

Documentation of assessments should specify the approximate time spent on each assessment task that totals the number of units billed. Documentation must always support the CPT codes and units billed. In addition to the specific documentation requirements listed in this topic, providers are also required to meet general behavioral treatment documentation requirements and electronic signature requirements for behavior identification assessment and plan of care development services to be reimbursable by ForwardHealth.

Documentation and data collection are allowed during the active provision of a covered patient-facing, skilled service. However, providers are reminded that ForwardHealth does not reimburse for time spent on documentation and record-keeping that interrupts the provision of skilled services or that occurs after a service is rendered. Documentation should be completed no later than 48 hours after the DOS as evidenced by the renderer's signature and signature date on the record.

Behavior Identification—Supporting Assessment

ForwardHealth covers behavior identification supporting assessment activities under CPT procedure code 97152 (Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes).

Behavior identification supporting assessments may be designed by a licensed supervisor and conducted by a licensed supervisor or treatment therapist to finalize or fine-tune the baseline results or plan of care. Supporting assessments may be billed up to two hours per DOS.

Documentation Requirements

In order for behavior identification supporting assessments to be reimbursable, providers are required to document all of the following:

• DOS
• Length of the session, including time in and out
• Mode of delivery (for example, in-person or telehealth) (Note: Telehealth requirements are available.)
• Names of staff and individuals present
• Assessments administered
• Renderer's signature and signature date

Documentation must always support the CPT codes and units billed. In addition to the specific documentation requirements listed in this topic, providers are also required to meet general behavioral treatment documentation requirements and electronic signature requirements for behavior identification supporting assessments to be reimbursable by ForwardHealth.

Documentation and data collection are allowed during the active provision of a covered patient-facing, skilled service. However, providers are reminded that ForwardHealth does not reimburse for time spent on documentation and record-keeping that interrupts the provision of skilled services or that occurs after a service is rendered. Documentation should be completed no later than 48 hours after the DOS as evidenced by the renderer's signature and signature date on the record.