Sandhills Center
B-3 Physician Consultation/ Psychiatric Consultation
(Adult Mental Health/Child Mental Health)
Medicaid Billable
02-25-2014
Revised 05-14-14
Revised 10-13-14
Communication between a primary care provider and a psychiatrist for a patient-specific consultation
that is medically necessary for the medical management of psychiatric conditions by the primary care
provider. This service is coverable under the State Plan under physician services.
A consultation service that provides brief, intermediate and extensive levels of consultation between a
Psychiatrist and a Primary Care Provider to ensure appropriate management of psychiatric conditions by
the Primary Care Provider. The individual must be a patient of the primary care provider. The
Psychiatrist may or may not observe the individual as appropriate as a component of the consultation.
This consultation may take the form of email, telephone, fax or face-to-face communication.
Staffing Requirements
Primary Care Provider or Board Certified in Adult or Child Psychiatry and holds a current license in the
state of NC.
Service Type/Setting
Psychiatric Consultation is a periodic service intended to ensure that Primary Care Providers have access
to appropriate consultation that is medically necessary for the medical management of psychiatric
conditions by the primary care provider. Services provided to individuals that are independently seen by
a psychiatrist should be billed under psychiatric CPT codes. This service is not available to a patient who
is under the care of another psychiatrist. This service may be provided in the office of the psychiatrist,
the primary care provider office or the facility where the individual lives.
Program Requirements
This service will be delivered by Psychiatrists that are contracted and credentialed by SHC and meet the
provider qualification policies, procedures, and standards established by the Division of MH/IDD/SA
Services and the requirements of 10A NCAC 27G. These policies and procedures set forth the
administrative, financial, clinical, quality improvement, and information services infrastructure
necessary to provide services.
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Utilization Management
This service does not require prior approval.
Brief: Simple or brief communication to report tests and/or lab results, clarity or alter previous
instructions, integration new information into the medical treatment plan or adjust therapy or
medication regimen. This level is typically provided in 15 minute increments.
Intermediate: Intermediate level of communication between the psychiatrist and the primary care
provider. Does not require face-to-face assessment of patient. To coordinate medical management of a
new problem in an established patient, evaluate new information and details and/or initiate a new plan
of care, therapy or medication regime. This level is typically provided in 16-30 minute increments.
Extensive: Complex or lengthy communication, such as prolonged discussion between the psychiatrist
and the primary care provider regarding a seriously ill patient, lengthy communication needed to
consider lab results, response to treatment, current symptoms or presenting problem. Staffing of case
between psychiatrist and primary care provider to consider evaluation findings and discuss treatment
recommendations, including medication regimen. This level is typically provided in 31-60 minute
increments.
Entrance Criteria
Must be under the care of a primary care provider, and requires a consultation between a psychiatrist
and their primary care practitioner for appropriate medical or MH treatment.
Adult ages 18 and older with Serious Mental Illness (SMI) and/or Severe and Persistent Mental Illness
(SPMI) and a LOCUS level of 0 (basic level) or greater.
Children ages 3-21 with serious emotional disturbance (SED) and a CALOCUS level of 0 (basic level) or
greater.
Continued Stay Criteria
The recipient continues to meet eligibility criteria and participant needs continue to require this service.
Discharge Criteria
Primary Care Provider no longer requires assistance with the individual’s psychiatric needs.
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Expected Outcomes
Amelioration or stabilization of psychiatric symptoms or appropriate referral to medically necessary
services to achieve psychiatric stabilization.
Service Documentation Requirements
Minimum standard is a progress note for each treatment encounter that meets the criteria specified in
Clinical Coverage Policy No. 8C, and includes, but not limited to, the recipient’s name, Medicaid
identification number, date of service, the name of the service, the duration of the service, purpose of
contact, describes the provider’s interventions including the time spent performing the interventions,
effectiveness of the intervention, the signature, credentials and licensure of the staff providing the
service. Refer to Clinical Coverage Policy No. 8C for a complete listing of documentation requirements.
Service Exclusions/Limitations
Total expenditures on Physician Consultation cannot exceed the 1915(b)(3) resources available in the
waiver.
Physician Consultation may not be provided by family members.
LME/MCO Monitoring and Quality Management Protocols for Review of Efficacy and CostEffectiveness of Alternative Service
Sandhills Center will monitor this service for quality and fidelity to the definition through billing audit
reviews.
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