Covered and Noncovered Services : Covered Services and Requirements

Family Adaptive Behavior Treatment Guidance

The aim of family adaptive behavior treatment guidance is to teach parents and/or caregivers to properly use treatment procedures designed to teach new skills and reduce challenging behaviors. Covered activities include face-to-face instruction to parents and/or caregivers, with or without the member present, with a focus on identifying problem behaviors and deficits following the POC, to reduce maladaptive behaviors and/or skill deficits.

ForwardHealth covers both team meetings and family treatment guidance under family adaptive behavior treatment guidance as these are considered related, but distinct, services. Team meetings and family treatment guidance require PA.

Family Treatment Guidance

ForwardHealth covers treatment guidance provided to the member's family and caregivers. This service must include specific measurable goals.

ForwardHealth covers family treatment guidance under CPT procedure code 97156 (Family adaptive behavior guidance, administered by physician or other qualified health care professional [with or without the patient present], face-to-face with guardian[s]/caregiver[s], each 15 minutes). Procedure code 97156 is used with modifier TG (Comprehensive level of service) or TF (Focused level of service), as appropriate. Family treatment guidance may satisfy the ForwardHealth direct patient observation requirements for licensed supervisors if clinical notes reflect that the member was present and the provider engages inactivities directly involving the member, such as demonstration protocols or coaching family members in the implementation of a protocol.

In order for family treatment guidance to be reimbursable, providers are required to document all of the following:

• DOS
• Information collected from the family
• Information shared with the family
• Length of the meeting, including time in and out
• Measurable family goals addressed
• Name of the licensed supervisor and family members or caregivers that were present
• Update of family goals resulting from the family treatment guidance session
• Renderer's signature

Regardless of the number of participants, family treatment guidance is reimbursed up to two hours per DOS. The licensed supervisor is required to be indicated as the rendering provider on the claim.

Team Meetings

ForwardHealth covers team meeting services with PA. In team meeting services, licensed supervisors or treatment therapists meet with a member's parent(s) or caregiver(s) and the behavioral treatment team to discuss the member's progress and to help the team and caregivers learn how to:

• Identify behavioral problems.
• Implement treatment strategies to minimize destructive behavior.
• Participate in the treatment of the member.

ForwardHealth covers team meeting services under CPT code 97156. Procedure code 97156 is used with modifier AM (Physician, team member service) in addition to modifier TG or TF, as appropriate. As indicated in the code description, the service is delivered "with or without the member present."

In order for team meeting services to be reimbursable, providers are required to document all of the following:

• Goals resulting from the meeting
• Learning objectives that were targeted
• Length of the meeting
• Names of the parents, caregivers, and team members who were present
• Comprehensive — In addition to the parents or caregivers, a licensed supervisor or treatment therapist and other treatment team member(s) must be present in order for the meeting to qualify as a team meeting
• Focused — In addition to the parents or caregivers, a licensed supervisor and other treatment team member(s) must be present in order for the meeting to qualify as a team meeting
• Outcome of the learning objectives
• Renderer's signature

Team meetings are reimbursed up to one hour per week, as long as PA is received from ForwardHealth. Team meeting services must be requested as a separate line item on the PA request. Regardless of the number of participants, the team meeting is reimbursed once per member per DOS. Either the licensed supervisor or treatment therapist — who must be documented as present and leading the meeting — is required to be indicated as the rendering provider on the claim. Team meeting services may satisfy the ForwardHealth direct patient observation requirements for licensed supervisors if clinical notes reflect that the member was present and provider engaged in activities directly involving the member, such as demonstration protocols or coaching team members in the implementation of a protocol.

PA requirements for team meeting services are available.

Further claim submission information is also available.

All documentation requirements must be met for team meeting services to be reimbursable by ForwardHealth.