ModifiedDHAPolicy 6010.60-M

Family Therapy

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This document window identifies DHA Policy 6010.60-M as the Family Therapy policy within the TRICARE behavioral health services section. The substantive coverage criteria, authorization requirements, coding, and clinical rules are not present in this window.

Policy Summary

PayerDHA

PolicyFamily Therapy

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateOct 3, 2016

Next Review DateNot specified

Key ActionRTCs and partial hospitalization programs must address the feasibility of family therapy in the treatment plan for authorization.

SourceLink

POLICY UPDATE CHANGES

Family therapy was added as cost-shareable when provided with otherwise covered treatment for a beneficiary with a diagnosed mental health or substance use disorder.

Requirements for family therapy in partial hospitalization and residential treatment center care were added or modified, including treatment-plan, admission, documentation, and collaboration requirements.

Quantitative limits on mental health care were removed.

3CPT procedure codes listed

250 milesDistant-parent threshold

2Facility-based settings with requirements

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ModifiedDHAPolicy 6010.60-M

Family Therapy

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Policy Summary

PayerDHA

PolicyFamily Therapy

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateOct 3, 2016

Next Review DateNot specified

Key ActionRTCs and partial hospitalization programs must address the feasibility of family therapy in the treatment plan for authorization.

SourceLink

POLICY UPDATE CHANGES

Family therapy was added as cost-shareable when provided with otherwise covered treatment for a beneficiary with a diagnosed mental health or substance use disorder.

Quantitative limits on mental health care were removed.

3CPT procedure codes listed

250 milesDistant-parent threshold

2Facility-based settings with requirements

Mental health care limits

Chapter 7Behavioral health chapter

Section 3.12Family Therapy section

Family Therapy Coverage Criteria

General Family Therapy Coverage

Family therapy is eligible for cost-sharing when ALL of the following requirements are met:

ALL of the following

The beneficiary has a diagnosed mental health or Substance Use Disorder (SUD).
The beneficiary is receiving otherwise covered treatment for the diagnosed condition.
Family therapy is rendered in conjunction with the otherwise covered treatment.
The therapy is directed toward the family as a unit and addresses family interactions related to the identified patient's mental or emotional illness and functional impairment. The family generally includes the patient's spouse and children; for a child patient, it includes the parents, stepparents, and siblings, and may include other household members when appropriate.

Partial Hospitalization and RTC Care

For partial hospitalization and Residential Treatment Center (RTC) care, coverage and authorization require ALL applicable treatment-planning requirements below:

ALL of the following

The RTC or partial hospitalization program addresses the feasibility of family therapy as part of the patient's treatment plan.
The admission process includes the family's, responsible relative's, or legal guardian's understanding of the residential or partial hospitalization treatment, their involvement in treatment, and the patient's probable length of stay (LOS).
The treatment plan spells out all specific therapeutic modalities, including family therapy.
When indicated, the treatment plan includes a specific plan for involving the family.
The patient's clinical record documents family members' involvement in the treatment program; when appropriate, a separate record is maintained for each participating family member.
ONE of the following applies

Children and Adolescents

For children and adolescents, family therapy requirements are subject to medical review based on the individual patient's needs.

ALL of the following

Family therapy is included in the mental health treatment plan.
ONE of the following applies
- No contraindicating circumstance exists, and family therapy is provided.
- Family therapy is contraindicated, and the treatment plan provides a rationale explaining why it is not being provided.

Geographically Distant Family

When the patient's family is geographically distant, the treatment setting must maintain an appropriate family-involvement plan and document the required coordination.

ALL of the following

If an RTC accepts a child whose parents are geographically distant, the RTC documents its plan for including the family in therapy in accordance with RTC standards and the appropriate medical care standard.
If one or both parents reside at least 250 miles from the RTC, the RTC may arrange therapy with the parents at their distant location while the child is receiving RTC treatment, or may provide family therapy by telemedicine in accordance with applicable telemedicine requirements.
The parent's therapist and the child's therapist collaborate in all cases, and the RTC documents that collaboration in the medical records.
For partial care, the program evaluates whether the child can return to the home setting daily and whether effective family interaction can be provided as part of the program.

Telephone calls, therapeutic leaves, and visits among family members are not substitutes for family therapy, although they may be important adjuncts to a child's treatment. Multi-family group therapy does not meet the family therapy requirement. A collateral visit between an authorized provider and a significant person in the identified patient's life, when primarily for information gathering, does not constitute a family therapy session.

Geographical distance of the patient's family is not an appropriate reason to exclude the family from the treatment plan. By accepting a child for admission, an RTC or Partial Hospitalization Program (PHP) acknowledges that it can provide treatment appropriate to the child's needs and is responsible for accepting only children it can help through an appropriate treatment program designed to maximize the patient's ability to function in one or more major life activities.

Covered Procedure Codes

Covered CPT CodesCPTCovered

90846	Family psychotherapy, without the patient present
90847	Family psychotherapy, conjoint psychotherapy with the patient present
90849	Multiple-family group psychotherapy

Authorization and Documentation Requirements

Prior Authorization

RTC/PHP Family-Therapy Planning

For RTC and partial hospitalization program (PHP) admissions, address the feasibility of family therapy in the treatment plan as a condition of authorization. Discharge planning should begin on the day of admission, with attention to restoring function and, for children under 21, the discharge environment.

Explain how family therapy will be provided and how it supports the patient's treatment and discharge plan.

Documentation Required

Admission and Treatment-Plan Documentation

At admission, document that the family, responsible relative, or legal guardian understands the residential or partial-hospitalization treatment, their expected involvement, and the patient's probable length of stay. The treatment plan and clinical record must identify all specific therapeutic modalities, including family therapy, and document family involvement; maintain separate records for participating family members when appropriate.

Include the family's or responsible party's understanding of treatment and involvement in the admission process.

Policy Background

Family therapy is psychotherapy directed toward the family as a unit rather than toward a single individual. It is based on the relationship between the identified patient's mental or emotional illness, functional impairment, and family interactions; the family may be complete or partially available and generally includes the patient's spouse, children, parents, stepparents, siblings, or other appropriate household members. Coverage may be cost-shared when family therapy is provided in conjunction with otherwise covered treatment for a beneficiary with a diagnosed mental health or substance use disorder.

Key Definitions

Family therapy

DefinitionPsychotherapy directed toward the family as a unit rather than a single individual.

BasisThe identified patient's mental or emotional illness and functional impairment are related to family interactions, so the family is the unit treated.

Family participationThe complete or partially available family unit may participate, normally with the same therapist or treatment team.

Covered family membersThe family generally includes the patient's spouse, children, or, for a child patient, parents, stepparents, and siblings; other household members may be included when appropriate.

Collateral visit

DefinitionA session between an authorized provider and a significant person in the identified patient's life conducted primarily for information gathering.

Partial Hospitalization and Residential Treatment Center

For residential treatment center and partial hospitalization admissions, the following treatment-planning requirements apply.

Admission planning: The admission process includes the family's, responsible relative's, or legal guardian's understanding of residential or partial hospitalization treatment, their involvement in treatment, and the patient's probable length of stay; the program addresses the feasibility of family therapy.

Applicable to partial hospitalization and residential treatment center admissions.

Ongoing treatment planning: The treatment plan specifies family therapy and all other specific therapeutic modalities, documents family involvement, and supports restoration of the patient's ability to function in one or more major life activities.

For children under age 21, the environment to which the patient will be discharged is a major consideration.

Discharge preparation: Discharge planning begins on the day of admission; when the patient will not return to the family, the clinical record documents the preparation made with the persons who will be involved with the patient after discharge.

Family Therapy Modalities

Family Therapy

When provided, family therapy must be identified and documented as a specific treatment modality.

Family therapy modality: Family therapy is specified in the treatment plan among the therapeutic modalities, and the clinical record documents family members' involvement in the patient's treatment program.

For children and adolescents, family therapy is included unless contraindicated; when omitted, the treatment plan must document the rationale, subject to medical review.

Telemedicine Family Therapy

Telemedicine may be used to provide family therapy when family members are geographically distant, subject to the following requirements.

Telemedicine family therapy: The RTC provides family therapy by telemedicine in accordance with existing telemedicine requirements, and the parent's therapist and child's therapist collaborate.One or both parents reside at least 250 miles from the RTC.

Policy Summary

PayerDHA

PolicyFamily Therapy

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateOct 3, 2016

Next Review DateNot specified

Key ActionRTCs and partial hospitalization programs must address the feasibility of family therapy in the treatment plan for authorization.

SourceLink

On This Page

The patient will return to the family after treatment.

If the patient will not return to the family, the RTC documents in the clinical record the preparation made with the other persons who will be involved with the patient upon discharge.

Applies to RTC care.

Spell out family therapy and other therapeutic modalities in the treatment plan.

Document family participation in the treatment program.

Documentation Required

Child and Adolescent Treatment Plans

Family therapy is an integral part of treatment for children and adolescents and should be included in every mental-health treatment plan unless contraindicated. If it is not provided, the treatment plan must state the specific rationale, which remains subject to medical review based on the individual patient's needs.

Include family therapy in child and adolescent treatment plans unless circumstances make it contraindicated.
Document the clinical rationale whenever family therapy is omitted.

Documentation Required

Distant-Family Documentation

Geographic distance does not justify excluding family from the treatment plan. When an RTC admits a child whose parents are distant, document the plan for including them in therapy, including collaboration between the parent’s and child’s therapists; collaboration is the RTC’s responsibility and must be documented in the medical record.

If a parent resides at least 250 miles from the RTC, arrange therapy at the distant location or use telemedicine consistent with applicable requirements.
A child may not be appropriate for PHP when effective family interaction cannot be provided in the home setting.
Document the RTC's plans and all therapist collaboration.

Documentation Required

Exception Rationale Required

When family therapy is inappropriate because of the particular circumstances of the case, include supporting documentation and a treatment-plan rationale. For example, explain the circumstances when the patient will not return to the family unit.

Do not rely on geographic distance alone as the reason to omit family therapy.
Provide case-specific clinical support for any exception.

Billing Rule

Services That Do Not Qualify as Family Therapy

The following services do not satisfy the family-therapy requirement, although some may be useful adjuncts to treatment: telephone calls, therapeutic leaves, visits among family members, multi-family group therapy, and collateral visits primarily conducted to gather information from a significant person in the patient's life.

Telephone calls, therapeutic leaves, and family visits are not substitutes for family therapy.
Multi-family group therapy does not meet the requirement.
A collateral visit is not family therapy.

Denial Risk

RTC Authorization Denial Risk

Authorization for RTC care shall be denied when the patient's treatment plan does not address the provision of family therapy. A documented pattern of facility treatment plans that fail to provide for family therapy may violate applicable standards and may indicate domiciliary care; such a pattern must be reported to DHA through the TRICARE Regional Office.

Ensure the RTC treatment plan addresses family therapy or includes documented, medically reviewed support for a specific contraindication.
Failure to address family therapy creates an RTC authorization denial risk.

Denial Risk

Complete Family-Therapy Planning

Before admitting a patient to RTC or PHP care, ensure the program has a feasible plan for family involvement and documents that plan in the treatment record. Inadequate planning—including failure to identify family participation, therapist collaboration, supporting documentation, or a case-specific rationale for an exception—creates a risk that care will not meet applicable standards or that RTC authorization will be denied.

Address family therapy feasibility in the treatment plan.
Document family, responsible-relative, or legal-guardian understanding and involvement.
Document distant-family arrangements and therapist collaboration when applicable.
Support any omission of family therapy with clinical documentation and rationale.

Coverage distinctionA collateral visit does not constitute a family therapy session.

Relationship to family therapyCollateral visits are not a substitute for family therapy.

The requirement is stated for residential treatment center standards.

The RTC is responsible for the collaboration, which must be documented in the medical records.