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Diagnostic Assessment

Revised: April 29, 2021

• Overview

• Eligible Providers

• Eligible Members

• Covered Services

• Standard Diagnostic Assessment

• Extended Diagnostic Assessment

• Adult Diagnostic Assessment Update

• Brief Diagnostic Assessment

• Interactive Complexity

• Noncovered Services

• Authorizations

• Billing

• Legal References

Overview

The diagnostic assessment (DA) is necessary to determine a member’s eligibility for mental health services through Minnesota Health Care Programs (MHCP). The DA is a written report that documents the clinical and functional face-to-face evaluation of a person’s mental health. The report must include the:

• Nature, severity and impact of behavioral difficulties

• Functional impairment

• Subjective distress

• Strengths and resources

Exception: The initial DA allows for an MHCP member to be eligible to receive up to three sessions of a combination of individual or family psychotherapy or family psychoeducation before the provider completes the diagnostic assessment.

In addition, the provider may perform the DA with or without medical services. Medical services include:

• Prescription of medications

• Reviewing and ordering laboratory services

• Other diagnostic studies

Eligible Providers

The following mental health professionals may enroll as an MHCP provider and render a diagnostic assessment:

• Clinical nurse specialist (CNS)

• Licensed independent clinical social worker (LICSW)

• Licensed marriage and family therapist (LMFT)

• Licensed professional clinical counselor (LPCC)

• Licensed psychologist (LP)

• Psychiatric nurse practitioner (NP)

• Psychiatrist

In addition, the following individuals may render a diagnostic assessment:

• An individual certified by tribal council as a mental health professional, serving a federally recognized tribe

• Mental health practitioners who qualify as clinical trainees

Clinical Supervision

Clinical supervision is the documented time a clinical supervisor and supervisee spend together to discuss the supervisee's work, to review individual client cases, and for the supervisee's professional development. It includes the documented oversight and supervision responsibility for planning, implementation and evaluation of services for a client's mental health treatment.

For more information, see the following:

• Eligibility for Clinical Supervision: See Minnesota Rule 9505.0371, subpart 4.

• Clinical Trainee qualifications: See Minnesota Rule 9505.0371, subpart 5C.

Eligible Members

All MHCP members are eligible for diagnostic assessment.

Covered Services

To be eligible for MHCP payment, a diagnostic assessment must:

• Identify a mental health diagnosis and recommend services, or determine the member does not meet the criteria for a mental health disorder. This is used as the factual basis to develop the member’s treatment plan.

• Include a face-to-face interview with the member and a written evaluation. Diagnostic assessments may be conducted using telemedicine technology when appropriate.

• Meet the conditions of one of the following four types of DA. Include a description of which of these types of DA is used in the written report:

• Standard diagnostic assessment

• Extended diagnostic assessment

• Adult diagnostic assessment update

• Brief diagnostic assessment

Document the medical necessity for mental health services in the diagnostic assessment.

Standard Diagnostic Assessment

The following can perform a diagnostic assessment with medical services:

• Psychiatrists

• Clinical nurse specialist-mental health (CNS-MH)

• Psychiatric nurse practitioner (NP)

Providers conduct a standard DA in the cultural context of the member, meaning the standard DA must be completed in a way that is relevant to the environment, situation, beliefs, values and practices of the member’s culture. It includes all of the components of the brief DA Minnesota Rules 9505.0372 and all of the following:

• The reason for the assessment, including the member’s:

• Perceptions of his or her condition

• Description of symptoms (including reason for referral)

• History of mental health treatment (including review of member’s records)

• Important developmental incidents

• Maltreatment, trauma or abuse issues

• History of alcohol and drug usage and treatment

• Health history and family health history, including physical, chemical and mental health history

• Cultural influences and their impact on the member

• An assessment of the member’s needs based on:

• Baseline measurements

• Symptoms

• Behavior

• Skills

• Abilities

• Resources

• Vulnerabilities

• Safety

• Assessment methods and use of standardized assessment tools

• Clinical summary, including recommendations and prioritization of needed mental health or other services

• Involvement of the member and member’s family in the assessment and his or her preferences or referrals to services

• Sufficient data to support findings on all axes of the current Diagnostic and Statistical Manual (DSM), and any differential diagnosis

Providers must complete a new standard DA for a child:

• At least annually following the initial DA if additional services are needed

• When a child does not meet the criteria for a brief or extended DA

• When the child’s mental health condition has changed markedly since the child’s most recent DA

• When the child’s current mental health condition does not meet criteria of the child’s current diagnosis

Providers may use a new standard DA for an adult:

• At least every three years following the initial standard or extended DA for an adult who receives services.

• When the adult does not meet the criteria for a brief DA or an adult update

• When the adult’s mental health condition has changed markedly since the adult’s most recent DA

• When the adult’s current mental health condition does not meet criteria of the adult’s current diagnosis

Extended Diagnostic Assessment

An extended DA includes all components of a standard DA, gathered over three or more appointments. The member requires significant additional assessment time due to complex needs, caused by:

• Acuity of psychotic disorder

• Cognitive or neurocognitive impairment

• A need to consider past diagnoses and determine their current applicability

• Co-occurring substance abuse use disorder

• Disruptive or changing environments

• Communication barriers

• Cultural considerations

Children

For a child, providers may conduct appointments outside the office, with or without the child present, for face-to-face consultation and information gathering with:

• Family members

• Doctors

• Caregivers

• Teachers

• Other providers

• Directly observing the child in various settings that the child frequents (home, school, care settings)

For children under age 5:

• Utilize the DC:0-3R diagnostic system for young children. For CTSS providers, utilize the Diagnostic Classification of Mental Health and Developmental Disorder of Infancy and Early Childhood DC 0-5.

• An early childhood mental status exam that assesses the child’s developmental, social and emotional functioning and style with the family and with the examiner and includes:

• Physical appearance including dysmorphic features

• Reaction to new setting and people and adaptation during evaluation

• Self-regulation, including sensory regulation, unusual behaviors, activity level, attention span and frustration tolerance

• Physical aspects, including motor function, muscle tone, coordination, tics, abnormal movements and seizure activity

• Vocalization and speech production, including expressive and receptive language

• Thought, including fears, nightmares, dissociative states and hallucinations

• Affect and mood, including modes of expression, range, responsiveness, duration and intensity

• Play, including structure, content, symbolic functioning and modulation of aggression

• Cognitive functioning

• Relatedness to parents, other caregivers and examiner

• Completion of other assessment tools may be determined and periodically revised by the commissioner

Providers must complete a new extended DA for a child:

• At least annually following the initial DA if additional services are needed

• When a child does not meet the criteria for a brief or standard DA

• When the child’s mental health condition has changed markedly since the child’s most recent DA

• When the child’s current mental health condition does not meet criteria of the child’s current diagnosis

Adults

For adults, Appointments may be conducted outside the office for face-to-face assessment with the adult and may include:

• Directly observing the adult in various settings that the adult frequents (home, school, job, service settings, community settings)

• Face-to-face meetings with:

• The adult and family members

• Doctors

• Caregivers

• Teachers

• Social support network members

• Recovery support resource representatives

• Other providers

• Completion of other assessment tools may be determined and periodically revised by the commissioner

Providers must complete a new extended DA for an adult when the adult:

• Does not meet the criteria for a brief or standard DA

• Has complex needs and requires at least three diagnostic appointments to complete the assessment, which allows further mental health services for one year

• Has a mental health condition that has changed markedly since the adult’s most recent diagnostic assessment

• Has a current mental health condition that does not meet criteria of the adult’s current diagnosis

• Needs documentation of covered services

• Has a medical necessity, individual treatment plan and progress note criteria the same as standard diagnostic assessment

Adult Diagnostic Assessment Update

For adults 18 years old and over, use an adult DA update to revise a standard or extended DA that has occurred:

• Within the past 12 months

• Within the past 24 months, when a previous adult diagnostic assessment update has occurred within the past 12 months

An adult DA update must include:

• Review of the member’s life situation

• Significant new or changed information, or documentation where there has not been significant change

• Screenings for substance use, abuse or dependency

• Mental status exam

• An assessment of the member’s needs based on:

• Baseline measurements

• Symptoms

• Behavior

• Skills

• Abilities

• Resources

• Vulnerabilities

• Safety

• Clinical summary, including recommendations and prioritization of needed mental health or other services

• Involvement of the member and member’s family in the assessment and his or her preferences or referrals to services

• Diagnosis on all axes of the current DSM

• Documentation of covered services

• Medical necessity, individual treatment plan and progress note criteria the same as standard diagnostic

Brief Diagnostic Assessment

A brief DA includes the member’s current life situation, including the following:

• Age

• Description of symptoms including reason for referral

• A mental status exam

• History of mental health treatment

• Cultural influences and their impact on the member

• Sufficient information for the professional or clinical trainee to document a provisional clinical hypothesis. The clinical hypothesis may be used to address the member’s immediate needs or presenting problem

Providers may use a brief diagnostic assessment for:

• A new member

• A member or a member’s family who require(s) a language interpreter to participate in the assessment

• An existing member who needs only medication management

• An existing member who had less than 10 sessions of psychotherapy in previous 12 months and is projected to need 10 or fewer psychotherapy sessions in the next 12 months

Treatment sessions conducted under authorization of a brief assessment may be used to gather additional information necessary to complete a standard diagnostic assessment or an extended diagnostic assessment.

Clinical Supervision

See Clinical Supervision of Outpatient Mental Health Services.

CTSS Requirements

CTSS requires an annual DA for children up to age 18 (CTSS annual DA exception). For adolescents age 18-21, only an annual adult DA update is required unless the mental health status has changed.

Interactive Complexity

Use the Interactive Complexity add-on code (90785) to designate a service with interactive complexity. Report interactive complexity for services when any of the following exist during the visit:

• Communication difficulties among participants that complicate care delivery related to issues such as:

• High anxiety

• High reactivity

• Repeated questions

• Disagreement

• Caregiver emotions or behaviors that interfere with implementing the treatment plan

• Evidence is discovered or discussed relating to an event that must be reported to a third party. This may include events such as abuse or neglect that require a mandatory report to the state agency

• The mental health provider overcomes communication barriers by using any of the following methods:

• Play equipment

• Physical devices

• An interpreter

• A translator for members who:

• Are not fluent in the same language as the mental health provider

• Have not developed or have lost the skills needed to use or understand typical language

Noncovered Services

Only a licensed mental health professional or clinical trainee working under clinical supervision can perform aspects of the DA.

Authorization

• Refer to Authorization for general authorization policy and procedures. Authorization is required to exceed two diagnostic assessment sessions per calendar year

• When requesting authorization for services that are to be performed with interactive complexity, include the interactive complexity add-on code on the authorization request

To request authorization, submit the following:

• MHCP Authorization Form (DHS-4695) (PDF) (except when using MN–ITS)

• Any past DAs, or an explanation of why it is not available and any attempts to obtain

• Written explanation of why the new DA is needed

Billing

Follow these guidelines for billing:

• Bill a diagnostic assessment (DA) online using MN–ITS 837P

• Complete all Diagnostic Assessment (DA) Report Components before billing a DA

• Enter the date of service for the DA as the date the written DA report is completed

• Enter the treating provider NPI number on each claim line

• Add appropriate modifiers for each type and when clinical trainees conduct the assessment

If a diagnostic assessment does not result in a diagnosis of mental illness or emotional disturbance, the provider is allowed to provide and bill for the following, if performed:

• 90887: One Explanation of Findings session

• 96130, 96138, 96146: Psychological Testing

Do not bill for diagnostic assessment on the same day as:

• E/M services provided by the same provider

• Psychotherapy services (any type)

Use the following table for billing services with date of service on or after Jan. 1, 2013:

|CPT Codes for Diagnostic Assessment |

|Code |Modifier |Brief Description |Unit |Limitations |

|90791 | |Standard diagnostic assessment |1 Session | |

| | | | | |

| | | | | |

| | | | |Maximum of four sessions, cumulative (90791 and 90792, all types) per calendar|

| | | | |year |

| | | | |A member may not receive more than two brief diagnostic assessments in a |

| | | | |calendar year |

| | | | |Interactive complexity add-on 90785 may be used with 90791 and 90792 |

| | | | |90792 may be provided by: |

| | | | |Clinical nurse specialist-mental health (CNS-MH) |

| | | | |Psychiatric nurse practitioner (NP) |

| | | | |Psychiatrist |

| | | | |Clinical trainees associated with these mental health professional types; Add |

| | | | |modifier HN for services provided by a clinical trainee |

| |52 |Brief diagnostic assessment | | |

| |TG |Extended diagnostic assessment | | |

| |TS |Adult update diagnostic assessment | | |

|90792 | |Standard diagnostic assessment with |1 Session | |

| | |medical services | | |

| |52 |Brief diagnostic assessment with | | |

| | |medical services | | |

| |TG |Extended diagnostic assessment with | | |

| | |medical services | | |

| |TS |Adult update diagnostic assessment | | |

| | |with medical services | | |

|Teaching hospitals may enter the GC modifier for services performed under the direction of a supervising physician. |

Legal References

Minnesota Rules 9505.0370, 9505.0371, 9505.0372 Mental health services

Minnesota Statute 245.461 Diagnostic codes list

Minnesota Statute 245.462 Definitions

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