Clinical UM Guideline
|Subject:||Basic Skills Training/Social Skills Training|
|Guideline #:||CG-BEH-10||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses basic skills training (BST) (also called social skills training). The medical necessity criteria outlined in this guideline for BST includes two categories: Severity of Illness and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. 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:
Severity of Illness (SI)
Basic skills training (BST) is considered medically necessary when All of the following are present:
Continued Stay Criteria (CS)
Continued authorization of basic skills training (BST) is considered medically necessary when ALL of 1-5 and 6 or 7 are present:
Not Medically Necessary:
BST is considered not medically necessary when the above criteria are not met.
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.
|H2014||Skills training and development, per 15 minutes|
|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-F99||Mental, behavioral and neurodevelopmental disorders|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|For the following diagnoses, including but not limited to:|
|290.0-319||Mental, behavioral and neurodevelopmental disorders|
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 used 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.
BST/social skills training groups have been described as an aspect of Adaptive Behavioral Treatment (ABT) provided for individuals with Autistic Spectrum Disorders (ASD's). Social skills training based on ABT principles uses a different approach, employing behavior modification, than the BST/social skills training described in this guideline.
Standard components of BST include:
Standard outcomes of BST include:
Use of Basic Skills Training/Social Skills Training in based on certain service expectations. A comprehensive functional assessment should be completed that identifies and documents the need for BST. Treatment goals should target resolution of cognitive and behavioral impairments consistent with the DSM-5/ICD diagnoses listed, through BST. Discharge plans should be individualized and include a projected discharge date. Training on medication management should be provided when medications are prescribed, and if not, there should be documentation of the reason and education addressing the lack of medication provided. Training addressing substance use/dependence should be provided when a diagnosis of substance use disorder is present or there is a risk for the development of a substance use disorder. Training for monitoring and communicating physical health should be provided and documented. Communication with the primary care provider or equivalent should be present. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist should be documented. Family participation in treatment should be documented unless contraindicated. If the family should not participate in BST, the record should provide an explanation. Community/natural supports and resources should be identified and utilized. Skills training should include 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. Treatment should not duplicate other services being provided for the same reasons/diagnoses. Services should be provided at the frequency and intensity needs of the member in accordance with benefit limits.
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 (such as, 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 (for example, maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||07/31/2015||Behavioral Health Subcommittee review. Multiple clarifications to Medical Necessity Criteria. Moved Intensity of Service criteria to Discussion/General Information section. Description, Discussion/General Information, Definition and Reference sections updated.|
|New||08/08/2014||Behavioral Health Subcommittee review. Initial document development|