Psychosocial services play an important role in helping beneficiaries with SPMI live successfully in the community, manage symptoms and medication side effects, and prevent relapse. Psychosocial services are heterogeneous and include a range of supports and therapies that vary considerably in their structure and duration.
When data was combined from all states, 73 percent of beneficiaries had at least one claim for some type of psychosocial service in 2007.6 However, this varied across states and the exact nature of these services is somewhat unclear in claims data. Some of the claims for psychosocial services are for specific EBPs, while the specific service being reimbursed using other claims is uncertain, as described below.
Based on a review of the literature and input from our advisory panel, the psychosocial services for schizophrenia and bipolar disorder with both the strongest evidence base and Medicaid billing codes include assertive community treatment (ACT), cognitive behavioral therapy (CBT), family therapy/psychoeducation, skills training, supportive employment, and psychotherapy.7 Identifying these psychosocial EBPs in Medicaid claims is difficult because billing codes for psychosocial services often lack specificity. For example, one state may use a billing code that clearly reimburses ACT while another state may reimburse ACT using a less specific billing code, labeled as “community support services.” Using claims data alone, we were unable to determine whether these nonspecific billing codes indeed are used for EBPs. Thus, state-to-state comparisons of the receipt of psychosocial EBPs using claims data alone can be misleading. In addition, psychosocial EBPs could be billed and paid as part of a larger bundled mental health service. For example, in some states, a beneficiary could receive CBT during a partial hospitalization visit.
We conducted an extensive review of national and state-specific billing codes used for psychosocial services. We identified nearly 50 national Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases (ICD) codes used for psychotherapy, and between 2 and 8 codes for ACT, CBT, family therapy or psychoeducation, skills training, and supported employment. Most states used some state-specific codes for psychosocial services, but the specific nature of the services being reimbursed was unclear for most codes, so it was not possible to determine whether the code was used to reimburse one of the psychosocial EBPs under investigation. Additionally, despite the large number of state-specific billing codes available for some psychosocial EBPs in some states, there was little correlation between the receipt of an EBP and the number of codes available. For example, one state had 127 state-specific codes that could be used for psychotherapy, but none of them actually were used for claims in 2007.
Given the limitations in identifying specific psychosocial EBPs, it is perhaps not surprising that there were few claims for psychosocial EBPs, with the exception of psychotherapy.8 When data were combined from all states, 59 percent of beneficiaries received at least one identifiable psychosocial EBP in 2007; most of those services were for some type of psychotherapy. Fifty-two percent of beneficiaries with schizophrenia and 60 percent of those with bipolar disorder had at least one identifiable claim for psychotherapy during 2007. Depending on the service, between 3 percent and 5 percent of beneficiaries had an identifiable claim for ACT, family therapy/psychoeducation, or skills training. Less than 1 percent of beneficiaries had an identifiable claim for supported employment or CBT. Again, the low number of claims for these services may be due, in part, to the lack of specificity of state Medicaid billing codes.
The difference in the proportion of beneficiaries who received a psychosocial EBP versus any psychosocial service is attributable both to the lack of specificity in billing codes to identify EBPs and the delivery of mental health services not considered EBPs (Table 1). In some states, the difference is small, whereas in others it is quite large. Nonetheless, in several states, 25-50 percent of beneficiaries did not have a claim for any psychosocial services.