Effective for dates of service on or after January 1, 2022, Non-Specialty Mental Health Services (NSMHS) are updated via managed care and fee-for-service delivery systems. NSMHS include the following:
- Mental health evaluation and treatment, including individual, group and family psychotherapy
- Psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition.
- Outpatient services for purposes of monitoring drug therapy
- Psychiatric consultation
- Outpatient laboratory, drugs, supplies and supplements
A managed care plan is required to provide these NSMHS to the following recipients:
- Recipients 21 years of age and older with mild to moderate distress or mild to moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current Diagnostic and Statistical Manual of Mental Disorders
- Recipients under 21 years of age, to the extent otherwise eligible for services through Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), regardless of level of distress or impairment, or the presence of a diagnosis, and
- Recipients of any age with potential mental health disorders not yet diagnosed
Detailed information regarding Specialty Mental Health Services (SMHS) and NSMHS may be found in the Non-Specialty Mental Health Services: Psychiatric and Psychological Services section of the provider manual and includes information on the following:
- Coverage of NSMHS and SMHS delivered prior to a diagnosis during the assessment period
- Coverage of NSMHS and SMHS delivered to recipients with a co-occurring mental health condition and substance use disorder
- Coverage of NSMHS and SMHS when delivered concurrently
- Coverage of mental health services for recipients who meet both NSMHS and SMHS criteria
The Psychiatry and Psychological Services sections of the provider manual have been merged and renamed Non-Specialty Mental Health Services: Psychiatric and Psychological Services.
Updates to NSMHS include the following:
- Clarification that recipients may self-refer for any form of psychotherapy delivered in an outpatient setting.
- Treatment Authorization Requests (TARs) are no longer required for psychotherapy in nursing facilities.
- Medical necessity criteria for psychotherapy are updated.
- Documentation requirements for psychiatric diagnostic evaluation are specified.
- The frequency limit for brief emotional/behavioral assessment (CPT® code 96127) is updated to two per day, per provider.
- Medical necessity criteria are specified for the following services:
- Aphasia assessment (CPT code 96105)
- Developmental testing (CPT codes 96112 and 96113)
- Neurobehavioral examination (CPT codes 96116 and 96121)
- Psychological testing (CPT codes 96130, 96131, 96136 thru 96146)
- Cognitive rehabilitation (CPT codes 97129 and 97130)
- Interactive complexity (CPT code 90785)
- Psychiatric diagnostic evaluation (CPT codes 90791 and 90792)
- The practitioner types for whom specific NSMHS are reimbursable have been updated.
- The allowable places of service for some NSMHS have been updated.
For more information regarding these updates, refer to the Non-Specialty Mental Health Services: Psychiatric and Psychological Services section of the provider manual.
For information about updated rates for NSMHS, refer to Non-Specialty Mental Health Services: Reimbursement Rates and Billing Codes and the Medi-Cal Rates page.
Medical team conference CPT codes 99366 and 99368 are reimbursable to licensed clinical social workers, licensed marriage and family therapists, licensed professional clinical counselors, psychologists, occupational therapists, physical therapists and social workers. CPT codes 99366 and 99368 are limited to conferences with persons immediately involved in the case or recovery of the client. The frequency limit for 99366 and 99368 is one per day, per provider. For more information, refer to the Evaluation and Management (E&M) section of the appropriate Part 2 provider manual.
Postpartum depression screenings billed using the child’s Medi-Cal ID require HIPAA-compliant documentation in the child’s medical record of the screening results and any recommendations/referrals that were given. For more information, refer to the Evaluation and Management (E&M) section of the appropriate Part 2 provider manual.
Durable Medical Equipment
Long Term Care
Orthotics and Prosthetics
|tar crit nf (1–4, 7, 8)
|Chronic Dialysis Clinics
||modif used (3, 6, 12, 15)
|Clinics and Hospitals
|eval (2, 5, 7, 9–11, 28, 33, 41, 42); modif used (3, 5, 12, 15); non ph (9); non spec mental (1–30); preg early (2); preg post (4)
||eval (2, 5, 7, 9–11, 28, 33, 41, 42); modif used (3, 5, 12, 15); non ph (9); preg early (2); preg post (4)
|Home Health Agencies/Home and Community-Based Services
||preg post (4)
||preg post (4); tar crit nf (1–4, 7, 8)
||non spec mental (1–30); non spec mental cd (1–6); tar crit nf (1–4, 7, 8)
||modif used (3, 5, 10, 13); non ph (9); tar crit nf (1–4, 7, 8)