USFHP is working with TRICARE on a process for auditing network behavioral health/mental health providers’ documentation of standardized measures in compliance with TOM Chapter 7, Section 6, Para 8. (CDRL A090). Records to audit the completion of these assessments may be requested for services starting in Oct. 1, 2023, at the start of the new contract year.

Behavioral Health Assessments

Specified assessments must be completed for all behavioral health settings and/or discharge from:

• Outpatient Mental Health and Substance Use Disorder (SUD)
• Opioid Treatment Programs (OTP)
• Intensive Outpatient Programs (IOPs)
• Partial Hospitalization Programs (PHPs)
• Psychiatric Residential Treatment Centers (RTCs)

As outlined in the TRICARE Policy Manual, Chapter 7, Section 3.10, the following standardized measures are required at treatment baseline, at 60-day intervals, and at discharge across all behavioral health settings (outpatient, inpatient, partial hospitalization, Residential Treatment Centers (RTC) and Substance Use Disorder Rehabilitation Facilities (SUDRF), for each individual (Covered Person) diagnosed with one of the three below conditions:

• Depressive Disorders (assessment using the PHQ-9 and for adolescents, PHQ-A)
• Anxiety Disorders (assessment using the GAD-7 for adults and adolescents)
• Post-Traumatic Stress Disorder (assessment using the PCL-5)

Billing for Behavioral Health Assessments

• Provider will use CPT Code 96127 or other agreed on CPT Code(s) that indicates an assessment was performed for claims filing so data may be generated and utilized to reflect response to treatment.
• CPT 96127 does not indicate which assessment was completed only that an assessment was performed.
• Provider to provide diagnosis data to identify which specific assessment was completed.

Behavioral Health Audit

USFHP is to conduct a twice-a-year statistically valid sample audit of behavioral health/mental health (BH/MH) providers and facilities to evaluate provider documentation of the completion of the appropriate standardized assessments upon diagnosis, and every 60 days through discharge.

• Depressive Disorders: Administer the PHQ-9; for adolescents, PHQ-A
• Anxiety Disorders: Administer the GAD-7; for adolescents
• Post-traumatic stress disorder: Administer the PCL-5

Administration of standardized measures will be validated for the age of the patient. The most current edition of the standardized measures shall be used. The provider may use clinical discretion to administer additional instruments as clinically indicated.

Key points about the audit

• All BH/MH settings are included in the audit.
• Audit required to report on total score for the relevant standardized assessment baseline, 60 days through discharge from care.
• The goal is to identify improvement in assessment score between assessments

Audit Requirements

• Population will be determined based on diagnoses for depressive disorders, anxiety disorder, and post-traumatic stress disorder, submitted via claims from qualified MH/BH providers.
• Using the Qualtrics calculator (95/5), USFHP will identify a statistically significant sample, or fifty (50) records, whichever is greater for the audit.
• USFHP will review records in the sample to evaluate documentation of completion of the appropriate assessments for each condition upon diagnosis, and every 60 days thereafter through discharge from care. The documentation must include the total assessment score results.

Guidance regarding treatment of mental health disorders

The treatment of mental health disorders such as mood disorders, anxiety disorders and post-traumatic stress disorder (PTSD) should be evidence-based, patient-centric and individualized to the member. Components of treatment typically include combinations of one or more of the following:

• Psychopharmacotherapy
• Verbal therapies (also known as “psychotherapy” or “counseling,” including individual, group, family)
• Other non-pharmacologic FDA-approved therapies (e.g., electroconvulsive therapy, transcranial magnetic stimulation)
• Behavioral therapies (e.g., motivational enhancement/interviewing, contingency management, encouragement of lifestyle changes such as promoting healthy sleep, diet and physical activity)
• Recovery supports (e.g., case management, services of peer recovery specialists, mobilization of safety measures or use of patient-facing mobile applications)
• Intensive services that provide a “protected setting,” such as inpatient hospitalization or residential rehabilitation
• Assessment for and addressing substance use problems

The use of any or all of these components, as well as the intensity and scope of services provided, should be determined based on an assessment of the member’s needs, strengths, weaknesses, resources, setting/context and, quite importantly, preferences and goals.

Due to the wide range of considerations this entails, there is no optimal treatment dosage/intensity or frequency of services that can be arbitrarily applied. The guiding principle that USFHP recommends is to start with the member’s report of problems they would like addressed, and goals they would like to achieve — both short-term and long-term. Then, any components of care as listed above should be presented to the patient, informing them of indications, alternatives, risks and benefits (informed consent). Decisions on course of treatment can be made collaboratively by the patient and provider.

During the course of treatment the member should be monitored for response to treatment (improvement or worsening), as well as side effects or unintended consequences of treatment. The provider should maintain a willingness to increase or decrease the amount/dose of treatment and add/subtract or change treatment components based on response, side effects and member preferences. If member preferences are not considered, engagement in treatment will be limited and outcome will certainly be suboptimal.

Referrals to specialty care should be facilitated for services or intensities of care that cannot be provided by the provider, and care across settings should be coordinated, maintaining adequate communication. Throughout this process, it is critical that member safety be assessed in an ongoing way, with attention toward suicidal ideation, self-injurious behavior, thoughts of violence and ability to care adequately for one’s self and one’s dependents.

USFHP stands ready to support our provider’s efforts and support our members throughout this process. This includes providing behavioral health case management services, which can assist both member and provider with accessing care, coordination of care and other supportive services.

• To access a behavioral health case manager, call us at 800-557-6916 or email [email protected].

Behavioral health IS health — and a vital component of your members’ lives. There are effective treatments available that can be administered in your own treatment setting or through appropriate referrals. USFHP can help providers and members navigate what is sometimes a complex system of care for a complex set of conditions and treatment components. The result of our collective efforts is a grateful member who feels that their concerns were heard and addressed and who not only feels better, but is more capable of managing their physical health challenges as well.

The use of evidence-based treatment is encouraged. Please see the below VHA/DoD Clinical Practice Guidelines for reference.

• VA/DOD Clinical Practice Guidelines | Health.mil
• Management of Major Depressive Disorder (MDD) (2022) - VA/DoD Clinical Practice Guidelines
• Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2023 - VA/DoD Clinical Practice Guidelines