PART I - Department of Behavioral Health and Developmental ...

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Substance Abuse Intensive Outpatient (SA Day Treatment)TransactionCodeUtilizationCriteriaServiceDefinitionCode Detail Code Mod1Mod2Mod3Mod4Rate Code Detail Code Mod1See Additional Medicaid Requirements below for billing codes, authorization, and unit information.LOCUS scores: 3 and 4-6 (transition)A time limited multi-faceted approach treatment service for adults who require structure and support to achieve and sustain recovery from substance related disorders.These services are available during the day and evening hours to enable individuals to maintain residence in their community, continue to work or go to school and to be apart of their family life. The following elements of this service model will include:1. Behavioral Health Assessment2. Psychiatric Treatment3. Nursing Assessment4. Diagnostic Assessment5. Community Support6. Individual Counseling7. Group Counseling (including psycho-educational groups focusing, relapse prevention and recovery)8. Family Counseling/Training (including psychoeducation) for Family MembersThe SA Intensive Outpatient Package emphasizes reduction in use and abuse of substances and/or continued abstinence; the negative consequences of substanceabuse; development of social support network and necessary lifestyle changes; educational skills; vocational skills leading to work activity by reducing substance abuse asa barrier to employment; social and interpersonal skills; improved family functioning; the understanding of addictive disease; and the continued commitment to a recoveryand maintenance program.Mod2Mod3Mod4RateAdmissionCriteriaServices are provided according to individual needs and goals as articulated in the treatment plan. The programmatic goal of the service must be clearly articulated by theprovider, utilizing the best/evidenced based practices for the service delivery and support that are based on the population(s) and issues to be addressed. Practitionersproviding this service are expected to maintain knowledge and skills regarding current research trends in best/evidence based practices.1. A DSM IV diagnosis of Substance Abuse or Dependence or substance- related disorder with a co-occurring DSM IV diagnosis of mental illness or DD; and2. The individual is able to function in a community environment even with impairments in social, medical, family, or work functioning; and3. The individual is sufficiently motivated to participate in treatment; andFY2013 Provider Manual for Community Behavioral Health Providers Page 132
AdmissionCriteria,continuedContinuingStay CriteriaDischargeCriteriaServiceExclusionsRequiredComponents4. One or more of the following:a. The substance use is incapacitating, destabilizing or causing the individual anguish or distress and the individual demonstrates a pattern of alcohol and/or druguse that has resulted in a significant impairment of interpersonal, occupational and/or educational functioning; orb. The individual’s substance abuse history after previous treatment indicates that provision of outpatient services alone (without an organized program model) isnot likely to result in the individual’s ability to maintain sobriety; orc. There is a reasonable expectation that the individual can improve demonstrably within 3-6 months; ord. The individual is assessed as needing ASAM Level II or III.1; ore. The individual has no significant cognitive and/or intellectual impairments that will prevent participation in and benefit from the services offered and has sufficientcognitive capacity to participate in and benefit from the services offered; orf. The individual is not actively suicidal or homicidal, and the individual’s crisis, and/or inpatient needs (if any) have been met prior to participation in the program.1. The individual’s condition continues to meet the admission criteria.2. Progress notes document progress in reducing use and abuse of substances; developing social networks and lifestyle changes; increasing educational, vocational,social and interpersonal skills; understanding addictive disease; and/or establishing a commitment to a recovery and maintenance program, but the overall goals ofthe treatment plan have not been met.3. There is a reasonable expectation that the individual can achieve the goals in the necessary reauthorization time frame.An adequate continuing care or discharge plan is established and linkages are in place; and one or more of the following:1. Goals of the treatment plan have been substantially met; or2. Consumer recognizes severity of his/her drug/alcohol usage and is beginning to apply skills necessary to maintain recovery by accessing appropriate communitysupports3. Clinical staff determines that consumer no longer needs ASAM Level II and is now eligible for aftercare and/or transitional servicesTransfer to a higher level of service is warranted by change in the1. Individual’s condition or nonparticipation; or2. The individual refuses to submit to random drug screens; or3. Consumer exhibits symptoms of acute intoxication and/or withdrawal or4. The individual requires services not available at this level or5. Consumer has consistently failed to achieve essential treatment objectives despite revisions to the treatment plan and advice concerning the consequences ofcontinues alcohol/drug use to such an extent that no further process is likely to occurServices cannot be offered with Mental Health Intensive Outpatient Package or Psychosocial Rehabilitation. When offered with ACT, documentation must indicate effortsto minimize duplication of services and effectively transition the individual to the appropriate services. This combination of services is subject to review by the ERO.1. This service must be licensed by DCH/HFR under the Rules and Regulations for Drug Abuse Treatment Programs, 290-4-2.2. The program provides structured treatment or therapeutic services, utilizing activity schedules as part of its operational method, i.e., plans or schedules of days ortimes of day for certain activities.3. These services should be scheduled and available at least 5 hours per day, 4 days per week (20 hrs/week), with no more than 2 consecutive days without serviceavailability for high need individuals (ASAM Level II.5). For programs that have a lower intensity program Level, it should be at least ASAM Level II.1 which includes 9hours of programming per week.FY2013 Provider Manual for Community Behavioral Health Providers Page 133
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Georgia Department of Behavioral He
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UPDATED FOR JULY 1, 2013SUMMARY OF
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C&A Core ServicesBehavioral Health
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Community Supportsupports;9) Assist
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