Clinical UM Guideline


Subject:  Psychosocial Rehabilitation Services
Guideline #:  CG-BEH-12Current Effective Date:  08/18/2014
Status:NewLast Review Date:  08/14/2014

Description

This document addresses psychosocial rehabilitation services (PRS). The medical necessity criteria outlined for PRS 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. 

PRS are programs provided to groups of individuals in a nonresidential setting for two or more consecutive hours per day. PRS includes assessment, education to teach the member about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. Services are more intense than traditional psychiatric services.

Members in PRS may also be considered for other services as consistent with medical necessity.

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. Impairments can include long-term or repeated psychiatric hospitalizations, difficulties in daily living, inability to function without intensive intervention, or limited to nonexistent support system; AND
  2. A well-defined clinical rationale is documented that explains why the member would benefit from psychosocial rehabilitation consistent with their DSM-5/ICD diagnosis; AND
  3. The Member demonstrates motivation for treatment and is capable of benefiting from PRS.

Intensity of Service (IS)

All of the following must be present:

  1. A written assessment completed that identifies and documents the needs for PRS; AND
  2. Person-centered planning should document goals, objectives and criteria for discharge from PRS in a fashion that reflects member goals, DSM-5/ICD diagnoses listed and the functional assessment. The planning process should be reviewed with the member every three months and rewritten no less often than annually; AND
  3. Service performed must teach the member about medication management and adherence when medications are prescribed, and if not, there is documentation of the reason and education addressing the lack of medication provided; AND
  4. Services addressing substance use disorder/dependence are provided when a diagnosis of substance use disorder is made; AND
  5. Services are performed that provide opportunities for the development of independent living skills and to enhance social and interpersonal skills; AND
  6. The member's primary care provider or equivalent is notified of PRS services, and there is collaboration on prioritizing treatment; 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 indicated; 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 but are not to exceed limits specified in the member's benefit plan. 

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and qualify as follows:

  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 service approach 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 PRS and treatment approach has been re-evaluated and changed if appropriate to include new goals/targets; AND
  4. The goals of PRS are not primarily for providing support; targets are not primarily functioning that is chronic and not likely to improve with the type of training being used, or primarily 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 acquired where sustained improvement is not likely, and the purpose of continued training is to prevent relapse or maintain previous achieved progress.

Not Medically Necessary: 

Psychosocial Rehabilitation Services (PRS) are 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 psychosocial rehabilitation services. Please contact the member's plan for applicable coding conventions as these may vary.

HCPCS 
H2017Psychosocial rehabilitation services, per 15 minutes
H2018Psychosocial rehabilitation services, per diem
  
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, including but not limited to:
F01.50-F99Mental, behavioral, and neurodevelopmental disorders
  
Discussion/General Information

PRS is sustained treatment that intends to restore a relatively full integration of members suffering from severe persistent mental illness into the community. Services are planned based on individual needs and can include support for medication adherence, treatment of substance abuse, therapy to enhance social and interpersonal skills, family participation and involvement in community activities. Improvement as the result of PRS may be exemplified by achieving member goals, improved social skills, decreased illness symptoms, improved quality of life and obtaining employment or successful school attendance. Randomized trials (RCT's) (Gigantesco, 2006; Shern, 2000; Swildens, 2011) and follow-up studies have not demonstrated consistent impact of PRS on the noted outcome variables with the most consistent finding being the accomplishment of member goals, a critical element in person-centered care.

Individuals suffering from chronic mental illness can benefit from services intended to restore function. A debilitating aspect of serious mental illness or serious emotional disorders is isolation from the larger community as the result of illness symptoms.

PRS should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a predetermined 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.

Standard outcomes of PRS include:

Definitions

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.

Psychosocial Rehabilitation (PRS): An especially intense type of outpatient care consisting of sustained treatment that intends to restore a relatively full integration into the community, exemplified by an ability to work or attend school. Services are planned based on individual needs and can include support for medication adherence, treatment of substance abuse, therapy to enhance social and interpersonal skills, family participation and involvement in community activities.

Severe and Persistent Mental Illness: A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results 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. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (National Committee for Quality Assurance [NCQA], 2014).

References

Peer Reviewed Publications: 

  1. Bartels SJ, Pratt SI. Psychosocial rehabilitation and quality of life for older adults with serious mental illness: recent findings and future research directions. Curr Opin Psychiatry. 2009; 22(4):381-385.
  2. 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.
  3. Gigantesco A, Vittorielli M, Pioli R, et al. The VADO approach in psychiatric rehabilitation: a randomized controlled trial. Psychiatr Serv. 2006; 57(12):1778-1783.
  4. 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.
  5. Shern DL, Tsemberis S, Anthony W, et al. Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health. 2000; 90(12):1873-1878.
  6. Svedberg P, Svensson B, Hansson L, Jormfeldt H. A 2-year follow-up study of people with severe mental illness involved in psychosocial rehabilitation. Nord J Psychiatry. 2014; 68(6):401-408
  7. Swildens W, van Busschbach JT, Michon H, et al. Effectively working on rehabilitation goals: 24-month outcome of a randomized controlled trial of the Boston psychiatric rehabilitation approach. Can J Psychiatry. 2011; 56(12):751-760.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. 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 2, 2014.
  2. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at:  http://app04.ncqa.org/faq/FAQReportList.asp?Product=146&PrintReport=Select+Report. Accessed on July 17, 2014.
  3. Virginia Department of Medical Assistance Services. Psychosocial Rehabilitation. Available at: http://www.dmas.virginia.gov/Content_atchs/obh/cmh-trngs8.pptx. Accessed on July 2, 2014.
  4. World Health Organization. International Classification of Functioning, Disability, and Health. Available at: http://www.who.int/classifications/icf/en/. Accessed on July 2, 2014.
History

Status

Date

Action

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