Clinical UM Guideline


Subject:  Targeted Case Management (TCM)
Guideline #:  CG-BEH-13Current Effective Date:  08/18/2014
Status:NewLast Review Date:  08/14/2014

Description

This document addresses Targeted Case Management (TCM), an outpatient mental health service that assists members in accessing behavioral health treatment, medical interventions, and educational, social, developmental, and other support services. The goal of TCM is to ensure access to needed services, appropriate service utilization, and treatment adherence. TCM does not include the direct delivery of these services. TCM services must be driven by the member's mental health needs.

The medical necessity criteria outlined in this document for TCM 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.

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 usual level of functioning and the ability to access behavioral health treatment, medical, and educational, social, developmental, and other support services.

To qualify, the symptoms must 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. The goals of TCM are not primarily for providing ongoing support and ensuring treatment adherence; members qualifying for this service include adults with severe and persistent mental illness and children and youth with serious emotional disturbance (SED). 

Severity of Illness (SI) 

Must have ALL of the following to qualify:

  1. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM-5/ICD diagnosis listed, and these disturbances/symptoms make the member unable to access behavioral health treatment, medical, educational, social, developmental or other supportive services required; AND
  2. The member demonstrates motivation for receiving support in accessing services and is capable of benefiting from this support; AND
  3. A well-defined clinical rationale is documented that explains why the member needs assistance in accessing behavioral health treatment, medical, educational, social, developmental, or other supportive services due to their specific symptoms.

Intensity of Service (IS)

Must have ALL of the following to qualify:

  1. Comprehensive case management assessment completed face to face prior to the provision of case management that includes an assessment of the following:
    1. Identifying information
    2. Family Life
    3. Physical health
    4. Emotional health
    5. Social relationships
    6. Physical environments
    7. Self-care
    8. Educational status
    9. Legal status
    10. Financial resources
    11. Community resources; AND
  2. Person-centered service plan based on the comprehensive assessment that  identifies behavioral health treatment, medical, educational, social, developmental, and/or other supports needing to be accessed by member and case manager's plan in assisting with this access; AND
  3. TCM goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM-5/ICD diagnoses listed, focusing on ensuring access and coordination to needed services; AND
  4. Discharge plans are individualized and include a projected discharge date; AND
  5. Medication needs are being monitored and treatment coordinated; AND
  6. If substance abuse/dependence is a diagnosis or indicated to be present, coordination with appropriate treatment providers is documented; AND
  7. Care is coordinated with the primary care provider or equivalent and is documented; AND
  8. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist is documented; AND
  9. Communication is promoted between all involved providers; AND
  10. Community/natural supports and resources are identified and linkage made, including school/work, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  11. Family participation is documented unless contraindicated with rationale noted; AND
  12. Services are provided in the member's natural environment, such as the individual's home, community organizations, and neighborhood; AND
  13. Providers must meet requirements, including but not limited to qualifications, caseload standards, contact frequency and duration requirements, and training requirements; AND
  14. All documentation must meet requirements for TCM including but not limited to monthly progress summaries; AND
  15. TCM services shall not include any non-covered services including but not limited to transportation, classroom observations, outreach to potential members, etc.

Continued Stay Criteria (CS)

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

  1. Documentation of members participation and engagement in TCM; AND
  2. Progress toward accessing needed services is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment and support services, improving severity of symptoms and functional impairment, and continued progress is expected; AND
  3. If progress is not documented, either member has been re-assessed and treatment needs have been re-evaluated and changed with new linkage needs; AND
  4. The member is allowing coordination of care with other providers and is involving family members where indicated and evidence of this is documented; for children/adolescents, the family is participating in treatment, adhering to recommendations, and demonstrating ability to coordinate services on member's behalf.

Not Medically Necessary: 

TCM 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 targeted case management. Please contact the member's plan for applicable coding conventions as these may vary.

HCPCS 
T1017Targeted case management, each 15 minutes
T2023Targeted case management; per month
  
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

Targeted Case Management (TCM) services facilitate and support access to care.  The services are designed to meet the needs of adults with severe and persistent mental illness as well as children, adolescents and families of children and adolescents with serious emotional disorders.  Unlike direct treatment, TCM facilitates service access, then supports adherence with treatment plans.  The primary focus is on mental health and substance abuse services.  Incorporation of management of illnesses outside of the behavioral health sphere can be an important element in TCM, in part recognition of the growing acceptance of the importance of non-behavioral health care.

Standard components of TCM include:

Standard outcomes of TCM include:

TCM should not be primarily for the avoidance of incarceration of the member or to satisfy 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 accessing treatment and medical, educational, social, developmental, and other supportive services.

Definitions

Outpatient Treatment: Outpatient treatment is 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, 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).

Targeted Case Management:  Targeted Case Management is used to assist adults and children who qualify for this service in maintaining access to needed medical, social, educational, and other services.

References

Peer Reviewed Publications: 

  1. Kirk TA, Di Leo P, Rehmer P, et al. A case and care management program to reduce use of acute care by clients with substance use disorders. Psychiatr Serv. 2013; 64(5):491-493.
  2. Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Serv. 2000; 51(11):1410-1421.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Department of Medicaid. Kentucky Medicaid Program Targeted Case Management Services Children Manual.  Available at: http://chfs.ky.gov/NR/rdonlyres/36B563C2-7B0E-4EEF-AD0B-B932D7B8AD2A/0/TCMChildrensmanual.pdf. Accessed on June 18, 2014.
  2. Kentucky Department of Behavioral Health, Developmental and Intellectual Disabilities. Kentucky Adult Targeted Case Management Training Manual. Available at: http://dbhdid.ky.gov/dbh/documents/TCMManual-Adult.pdf. Accessed on June 18, 2014.
  3. Rosenbaum S. The CMS Medicaid targeted case management rule: Implications for special needs service providers and programs. Center for Health Care Strategies Inc. Available at: http://www.chcs.org/resource/the-cms-medicaid-targeted-case-management-rule-implications-for-special-needs-service-providers-and-programs/. Accessed on July 1, 2014.
Websites for Additional Information
  1. 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 18, 2014.
History

Status

Date

Action

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