October 22, 2012

Dear Provider:

In reviewing cases to determine eligibility for Mental Health Targeted Case Management (MH-TCM) services, South Country Health Alliance (SCHA) has noticed that some diagnostic assessments have not been meeting the requirements specified in Minnesota statute and rule. In order to determine eligibility for Mental Health Targeted Case Management services, an extended or standard diagnostic assessment needs to be conducted. A recipient must meet criteria for serious and persistent mental illness (SPMI) for adults or severe emotional disturbance (SED) for children to meet criteria for Mental Health Targeted Case Management. A new standard or extended diagnostic assessment must also be completed at least every three years following the initial diagnostic assessment for individuals receiving Mental Health Targeted Case Management Services to determine a recipient has continued eligibility for Mental Health Targeted Case Management services.

Therefore, SCHA is providing the following information outlining requirements pertaining to diagnostic assessments. In addition, SCHA is taking this opportunity to highlight areas where diagnostic assessments have been lacking information and areas that need improvement in order for providers to continue to receive payments for these diagnostic assessments.

Diagnostic Assessments:

A diagnostic assessment is a written report that documents clinical and functional face-to-face evaluation of a recipient’s mental health, including the nature, severity and impact of behavioral difficulties, functional impairment, and subjective distress of the recipient, and identifies the recipient’s strengths and resources. A diagnostic assessment is necessary to determine a recipient’s eligibility for mental health services.
These requirements are specified in statute, rule and in the Minnesota Health Care Programs Manual (MHCP). See Minnesota Statutes: M.S. 245.462, M.S. 245.4871,and Minnesota Rules: M.R. 9505.0322, 9505.0370, 9505.0371, 9505.0372 and in the Minnesota Health Care Programs Manual (MHCP) which can be accessed via these links:

Statute:

Rule:

MHCP:


Diagnostic Assessments Eligible for Payment:

  • To be eligible for payment, a diagnostic assessment must:
  • Meet the conditions of the selected diagnostic assessment type (see below)
  • Identify a mental health diagnosis and recommended mental health services which are the factual basis to develop the recipient’s mental health services and treatment plan; or include a finding that the recipient does not meet the criteria for a mental health disorder.
  • Be a face-to-face interview with the recipient and a written evaluation. [M.R. 9505.0322]
  • To be eligible for medical assistance payment, the diagnostic assessment required for a determination of a recipient's eligibility to receive mental health case management services must comply with the requirements of Minnesota Rule, parts 9505.0370 to 9505.0372. Additionally, the diagnostic assessment must identify the needs that must be addressed in the recipient's individual treatment plan if the recipient is determined to have a serious and persistent mental illness or a severe emotional disturbance. [M.R. 9505.0322]
  • There are four types of diagnostic assessments when they are provided in accordance with the requirements as explained in each type. [M.R.9505.0371, subp. 2 and 9505.0372, subp. 1]
  • The four types of diagnostic assessments are:
  • Brief Diagnostic Assessment (Note: A brief diagnostic assessment cannot be used to determine eligibility for MH-TCM services.)
  • Standard Diagnostic Assessment
  • Extended Diagnostic Assessment
  • Adult Diagnostic Assessment Update (Note:An adult DA update cannot be used to determine initial eligibility for MH-TCM or at three years when determining continued eligibility for MH-TCM)
  • In addition, the Diagnostic Assessment Report components (M.R. 9505.0372, subpart 1 items A-E) are summarized in the attached document:

Eligibility for Mental Health Targeted Case Management:

SCHA requires prior authorization for MH-TCM. In determining whether someone is eligible to receive MH-TCM services, the determination must be based on a diagnostic assessment of the person and the person must have a diagnosis of either Serious and Persistent Mental Illness (SPMI) if an adult; or Severe Emotional Disturbance (SED) if a child under age 18 years.

For the purposes of case management and community support services, a “person with serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the following criteria [M.S. 245.462, subd. 20]:

  1. the adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;
  2. the adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six monthsduration within the preceding 12 months;
  3. the adult has been treated by a crisis team two or more times within the preceding 24 months;
  4. the adult:
  5. has a diagnosis of schizophrenia, bipolar disorder, major depression, or borderline personality disorder;
  6. indicates a significant impairment in functioning; and
  7. has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;
  8. the adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s commitment has been stayed or continued; or
  9. the adult: (i) was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871,subd. 6;and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided.

For purposes of eligibility for case management and family community support services “child with severe emotional disturbance” means a child who has an emotional disturbance and who meets one of the following criteria [M.S. 245.4871, subd. 6]:

  1. the child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment for an emotional disturbance; or
  2. the child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate compact; or
  3. the child has one of the following as determined by a mental health professional:
  4. psychosis or a clinical depression; or
  5. risk of harming self or others as a result of an emotional disturbance; or
  6. psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year; or
  7. the child, as a result of an emotional disturbance, has significantly impaired home, school, or community functioning that has lasted at least one year or that, in the written opinion of a mental health professional, presents substantial risk of lasting at least one year.

Continued Eligibility for MH-TCM:

A recipient’s continued eligibility for MH-TCM must be determined every 36 months. The determination of whether the recipient continues to have a diagnosis of SPMI or SED must be based on updating the recipient’s diagnostic assessment or on the results of conducting a complete diagnostic assessment because the recipient’s mental health status or behavior has changed markedly. Unless a recipient’s mental health status or behavior has changed markedly since the recipient’s most recent diagnostic assessment, only updating is necessary. If the recipient’s mental health status or behavior has changed markedly, a new diagnostic assessment must be completed. [M.R. 9505.0322, subp. 5]

Examples of lack information noted in Diagnostic Assessments

Adults with SPMI (M.S. 245.462, subd. 20)
For the purposes of case management and community support services, a “person with serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the following criteria:
Statute provision / What is lacking in Diagnostic Assessment
  1. The adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months
/
  • No dates provided for inpatient care
  • DA states “see previous record” – nothing attached or explained

  1. The adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months duration within the preceding 12 months:
/
  • No reference to psychiatric hospitalization dates
  • Confusing adult foster homes as being residential treatment and basing eligibility on living in adult foster home
  • May have had previous psychiatric hospitalization or residential treatment but it did not exceed 6 months duration and did not occur within the preceding 12 months
  • States “see previous record” and nothing attached and nothing is explained

  1. The adult has been treated by a crisis team two or more times within the preceding 24 months;
/
  • States was treated by a crisis team but doesn’t specify dates or timeframes or identify the crisis service provider
  • States “see previous record” and nothing attached and nothing is explained

  1. The adult:
  2. Has a diagnosis of schizophrenia, bipolar disorder, major depression, or borderline personality disorder;
  3. Indicates a significant impairment in functioning; and
  4. Has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonable likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;
/
  • Lacks narrative description for items contained in the diagnostic assessment
  • May have diagnosis but no information provided on significant impairment of functioning
  • Often times use symptom checklist with no narrative provided
  • Medications not listed or medications listed aren’t common treatment course for diagnosis listed
  • No information as to current mental health symptoms or how symptoms have changed if an adult DA Update was done
  • No impact on how diagnosis is impacting ability to function
  • No written opinion listed outlining why likely to future episodes requiring inpatient or residential treatment or only checkbox marked indicating this but no explanation provided

  1. The adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s commitment has been stayed or continued; or
/
  • If committed, no dates are specified
  • Sometimes was committed under CD and not MH

  1. The adult: (i) was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871, subd. 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided.
/
  • No written opinion listed outlining why likely to future episodes requiring inpatient or residential treatment or only checkbox marked indicating this but no explanation provided

Children (M.S. 245.4871, subd. 6):
For purposes of eligibility for case management and family community support services “child with severe emotional disturbance” means a child who has an emotional disturbance and who meets one of the following criteria:
Statute provision / What is lacking in Diagnostic Assessment
  1. The child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment of an emotional disturbance; or
/
  • States previous inpatient treatment or residential treatment but no dates/timeframes or facility specified

  1. The child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate compact; or

  1. The child; has one of the following as determined by a mental health professional:
  2. Psychosis or a clinical depression; or
  3. Risk of harming self or others as a result of an emotional disturbance; or
  4. Psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year; or
/
  • May list diagnosis but no narrative to support diagnosis given
  • May list risk of harming self/others but no explanation provided
  • May list person was a victim but no information provided

  1. The child, as a result of an emotional disturbance, has significantly impaired home, school, or community functioning that has lasted at least one year or that, in the written opinion of a mental health professional, presents substantial risk of lasting at least one year.
/
  • Lists diagnosis but does not provide information to show significant impairments in functioning
  • No written opinion listed or only checkbox provided with no narrative to provide support for opinion

If you would like further training on completing Diagnostic Assessments, the Minnesota Department of Human Services offers webinar training. The training segments can be found at the following links:

(training pertaining to diagnostic assessments)

(this link shows you how to register for training events)

(this link has DA PowerPoint documents for DA training)

If you have questions regarding this information, please contact either:

Joan Monahan
Mental Health & Chemical Health Manager
Direct line: 507-431-6369
Fax: 507-431-6329
Email: / or / Mary Schwieters
Chemical Health and Mental Health Coordinator
Direct line: 507-431-6377
Fax: 507-431-6329
Email:

Sincerely,

South Country Health Alliance

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