Clinical UM Guideline


Subject:  Basic Skills Training/Social Skills Training
Guideline #:  CG-BEH-10Current Effective Date:  08/18/2014
Status:NewLast Review Date:  08/14/2014

Description

This document addresses basic skills training (BST) (also called social skills training). The medical necessity criteria outlined in this guideline for BST includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.  

BST is a rehabilitative service whose goal is to reduce cognitive and behavioral impairment and restore recipients to their highest level of functioning. BST uses positive reinforcement, modeling, operant conditioning, and other training techniques and aligns these techniques to the cognitive and behavioral impairments of a mental health condition. The member's mental health condition requires training in functional skills, appropriate behaviors, activities of daily living, use of community resources, assistance with medication management, and monitoring of health, nutrition, and physical health. BST is not companion care. 

Note: Please see the following related document(s) for additional information:

Clinical Indications

Medically Necessary:

Interventions will focus on the presenting symptoms and complaints that have led to a decrease in the member's cognitive and behavioral functioning.

To qualify, the member must experience symptoms that meet the diagnostic criteria for a diagnosis from Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or International Classification of Diseases (ICD) for psychiatric outpatient treatment covered by the member's plan.

Severity of Illness (SI)

All of the following must be present:

  1. Significant cognitive and behavioral impairments that impedes the member's ability to live successfully in the community, and are consistent with the DSM-5/ICD diagnosis listed, and these impairments are likely to improve with treatment; AND
  2. A well-defined clinical rationale is documented that explains why the member would benefit from BST consistent with their DSM-5/ICD diagnosis; AND
  3. The member demonstrates motivation for treatment and is capable of benefiting from the BST planned.

Intensity of Service (IS)

All of the following must be present:

  1. A written functional assessment completed that identifies and documents the need for BST; AND
  2. Treatment goals target resolution of cognitive and behavioral impairments consistent with the DSM-5/ICD diagnoses listed, through BST; AND
  3. Discharge plans are individualized and include a projected discharge date; AND
  4. Training on medication management is provided when medications are prescribed, and if not, there is documentation of the reason and education addressing the lack of medication provided; AND
  5. Training addressing substance use/dependence is provided when a diagnosis of substance use disorder is present or there is a risk for the development of a substance use disorder; AND
  6. Training for monitoring and communicating regarding physical health needs is provided and there is documented communication with the primary care provider or equivalent; AND
  7. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist is documented; AND
  8. Community/natural supports and resources are identified and utilized and skills training includes the development of  and communication with community/natural supports, including school/work, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  9. Family participation in treatment is documented unless contraindicated with rationale noted; AND
  10. Treatment is not duplicative of other services being provided for the same reasons/diagnoses; AND
  11. Services must be provided at the frequency and intensity needs of the member in accordance with benefit limits.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Documentation of member's participation and engagement in services; AND
  2. Progress with the targeted functioning is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment, improving severity of functional impairment, and continued progress is expected for the targeted skills with the training approaches being used; AND
  3. If progress is not documented, either diagnosis has been re-evaluated and changed if appropriate, medication has been re-evaluated and changed if indicated, or BST and treatment approach has been re-evaluated and changed if appropriate to include new goals/targets; AND
  4. The goals of BST are not primarily for providing support for functioning unlikely to improve with the type of training being used, or self-improvement; AND
  5. Functional impairment of at least moderate degree as evidenced by report of specific domains are still present related to the DSM-5/ICD diagnosis listed and likely to improve with continued training; AND
  6. Skills have not been restored to the point where sustained improvement is not likely and the purpose of continued training is to prevent relapse or maintain previous achieved progress. 

Not Medically Necessary: 

BST is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Note: The following list of procedure codes are examples only and may not represent all codes being used for basic or social skills training. Please contact the member's plan for applicable coding conventions as these may vary.

HCPCS 
H2014Skills training and development, per 15 minutes
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 For the following diagnoses, including but not limited to:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses codes, including but not limited to:
F01.50-F99Mental, behavioral and neurodevelopmental disorders
  
Discussion/General Information

Basic Skills Training (BST) services (also referred to as social skills training services) are psychiatric rehabilitation interventions designed to assist persons to reduce cognitive and behavioral impairment, gain new basic life and social skills, and to achieve their highest possible level of adaptive functioning in their community and social environment (for example, family, education, employment).

BST should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a predetermine number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness. The population served by BST may be burdened with severe and persistent mental illness.

Standard components of BST include:

Standard outcomes of BST include:

Definitions

Basic Skills Training: Psychiatric rehabilitation interventions designed to assist persons to reduce cognitive and behavioral impairment, gain new basic life and social skills, and to achieve their highest possible level of adaptive functioning in their community and social environment (e.g. family, education, employment). Also referred to as social skills training.

Outpatient Treatment: A level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the member individually, in family therapy, or in a group modality.

Severe and Persistent Mental Illness: A mental illness resulting in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year.

References

Peer Reviewed Publications: 

  1. Bowie CR, McGurk SR, Mausbach B, et al. Combined cognitive remediation and functional skills training for schizophrenia: effects on cognition, functional competence, and real-world behavior. Am J Psychiatry. 2012; 169(7):710-718.
  2. Chien WT, Leung SF, Yeung FKK, Wong WK. Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care. Neuropsychiatr. Dis Treat. 2013; 9:1463-1481.
  3. Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia.  J Consult Clin Psychol. 2008; 76(3):491-504.
  4. Mueser KT, Deavers F, Penn DL, Cassisi JE. Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol. 2013; 9:465-497.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Nevada Department of Health and Human Services.  Medicaid Services Manual, Section 400. Mental Health and Alcohol/Substances Abuse Services. Available at http://www.dhcfp.nv.gov. Accessed on July 1, 2014. 
  2. World Health Organization. International Classification of Functioning, Disability, and Health. Available at: http://www.who.int/classifications/icf/en/. Accessed on July 1, 2014.
  3. State of Connecticut Department of Mental Health & Addiction Services. Available at http://www.ct.gov/dmhas/lib/dmhas/publications/CSP-SkillsTraining.pdf. Accessed on July 1, 2014.
  4. Boston University Center of Psychiatric Rehabilitation. A Primer on the Psychiatric Rehabilitation Process. Available at: http://www.bu.edu/cpr/products/books/titles/prprimer.pdf. Accessed on July 1, 2014.
  5. VA Psychosocial Rehabilitation Training Program: Social Skills Training for Serious Mental Illness. Available at: http://www.mirecc.va.gov/visn5/training/sst/sst_clinicians_handbook.pdf. Accessed on July 1, 2014.
History

Status

Date

Action

New08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
New08/08/2014Behavioral Health Subcommittee review. Initial document development