Rule 5160-27-06 | Therapeutic behavioral group service-hourly and per diem.
(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs of the client. The therapeutic behavioral group service-hourly and per diem is clinically indicated by assessment. The environment at this level of treatment is highly structured, and has an appropriate staff-to-client ratio to guarantee sufficient therapeutic services and professional monitoring, control, and protection. The purpose and intent of therapeutic behavioral group service-hourly and per diem is to stabilize, increase or sustain the highest level of functioning.
(1) Therapeutic behavioral group service-hourly and per diem must be a group treatment service that includes but is not limited to the following:
(a) Skills development of interpersonal and social competency, problem solving, conflict resolution, and emotions/behavior management,
(b) Developing of positive coping mechanisms,
(c) Managing mental health and behavioral symptoms to enhance independent living, and
(d) Psychoeducational services including instruction and training of persons served in order to increase their knowledge and understanding of their psychiatric diagnosis(es), prognosis(es), treatment, and rehabilitation in order to enhance their acceptance, increase their cooperation and collaboration with treatment and rehabilitation, and favorably affect their outcomes.
(B) Service requirements.
(1) When the service is provided for less than 2.5 hours per day, the therapeutic behavioral group service hourly billing code must be used.
(2) When the service is provided for 2.5 or more hours per day, the therapeutic behavioral group service per diem must be used and the service must:
(a) Be delivered at a nationally-accredited program and must be provided by a licensed practitioner, or an unlicensed mental health practitioner as described in paragraph (A)(2) of rule 5160-27-08 of the Administrative Code.
(b) The staff to client ratio cannot exceed 1:12.
(C) Limitations.
(1) Reimbursement for therapeutic behavioral group service-hourly and per diem will not be made while the patient is enrolled in assertive community treatment (ACT), or a substance use disorder (SUD) residential treatment facility.
(2) For adults, reimbursement for the following medically necessary behavioral health group services will be limited to no more than four fifteen-minute units, or one hour per day on the same day as the therapeutic behavioral group service (hourly, or per diem) except when prior authorized.
(a) Group psychotherapy for mental health or substance use disorder diagnoses.
(b) Group therapeutic behavioral services as defined in rule 5160-27-08 of the Administrative Code.
(c) SUD group counseling.
(d) Group community psychiatric supportive treatment.
(3) A therapeutic behavioral group service per diem and therapeutic behavioral group service hourly reimbursement will not be reimbursed when delivered on the same day by the same billing provider for the same individual.
(4) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day per provider. Reimbursement of therapeutic behavioral group service per diem and therapeutic behavioral service hourly by more than one billing provider to the same individual on the same day is allowable with prior authorization.
(5) Other behavioral health individual services may be reimbursed on the same day as therapeutic behavioral group service-hourly or therapeutic behavioral group service per diem.
(D) Providers must adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.
Last updated March 1, 2022 at 8:33 AM
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