- Admission - A clinical process that occurs after a patient has completed an assessment, received a recommendation for placement into a level of care and been accepted for such treatment. Covered services provided to patients whose assessment does not result in a substance abuse or dependence diagnosis cannot be billed.
- Discharge - occurs when the patient's treatment is terminated either by completion or by some other action initiated by the patient and/or organization. Providers cannot bill day of discharge for Residential Rehabilitation services to youth.
Level I and II services delivered in a group setting shall be reimbursed only for 16 patients per counseling group supported by Department funding (Medicaid or contract).
Billings Linked to Level of Care
Billings should match the Level of Care for the patient. Outpatient care (Level I or II) cannot be billed on the same day as Residential care (Level III). Admission and discharge assessment, psychiatric evaluation and medication monitoring may be billed on the same day for any patient in any Level of Care in accordance with stated eligibility, limits, or exceptions.
- Level III Care - Patient Day - No more than one patient day shall be reimbursed for any recipient in a 24-hour period.
- Day of Discharge or Transfer - Level III - Billing for the day of discharge or transfer is allowable if services are delivered on that day. The day of discharge or transfer in a Residential Rehabilitation program cannot be billed. However, in accordance with the billing provisions specified above, only services in one Level of Care may be billed for per patient per day. For example, for any patient transferred to another level of care within the same organization, only one type of billing for services rendered that day will be allowed, i.e., if the patient was transferred from Level III care into Level I or II care and received both types of services on that same day, billing in this instance would be allowed for a Level III day treatment OR an hourly group or individual rate but not for both. Similarly, when a patient is discharged by one organization and transferred, via linkage agreement, to another organization for the same or a different level of care, only one organization may bill for service delivered on that day. The other provider may bill their contract if applicable. However, if the Medical Benefits, All Kids and Family Care were not billed, the referring and receiving organizations may both bill their contract for any services rendered on the day of discharge.
- The day of discharge or transfer in an adolescent Residential Rehabilitation (Psychiatric Residential Treatment Facility) program cannot be billed.
Such services are limited to the provision of a psychiatric evaluation to determine whether the patient's primary condition is attributable to the effects of alcohol or drugs or to a diagnosed psychiatric or psychological disorder. Reimbursable psychiatric evaluations may be delivered to patients admitted to Level I through III care where need for such services is documented in the patient's individualized treatment plan. Psychiatric evaluation shall be reimbursed at the established rate on a per encounter basis (one per day). This service must be delivered by the agency's psychiatrist.
Psychotropic Medication monitoring must be billed at the individual counseling rate for patients in Level I, II and III care. Psychotropic medication monitoring includes a review of the efficacy, dosage and side effects of any psychotropic medication used by the patient. This type of medication monitoring shall also be conducted by the agency's physician or psychiatrist and billed at the individual counseling rate.
Billing Clarification for Methadone Patients
Medical Benefits, All Kids and Family Care - Providers can bill for Level I counseling services to DARTS if the site is certified and enrolled. Methadone providers who bill Level I services to the Medical Benefits, All Kids and Family Care must correctly report these services on DARTS using the Methadone unit number and program code which contains the standard Level I procedures code(s) (OPG, OPI, PEV).
In addition, eligible providers can also bill and receive reimbursement for Methadone patients who require Level II or III services even if they or another provider is receiving the case rate for outpatient Methadone services. In these instances, Methadone specific services that are considered part of the "all inclusive" case rate may not be part of the Level II and III care and must be delivered in addition to the Level II and III care.