CurrentNorth Carolina MedicaidPolicy N/A

Partners Individual Rehabilitation, Coordination, and Support (IRCS) Services

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This policy governs North Carolina Medicaid coverage and delivery requirements for Partners Individual Rehabilitation, Coordination, and Support services for adults age 18 and older with serious and persistent mental illness and/or substance use disorder.

Policy Summary

PayerNorth Carolina Medicaid

PolicyPartners Individual Rehabilitation, Coordination, and Support (IRCS) Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain an authorized practitioner service order before or on the day IRCS services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

H0217U5Procedure code

15 minUnit

10 hr/weekMaximum

2,080 unitsAnnual average

18+

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CurrentNorth Carolina MedicaidPolicy N/A

Partners Individual Rehabilitation, Coordination, and Support (IRCS) Services

Customize your policy alerts

Sign up for all North Carolina Medicaid policy alerts

Know when North Carolina Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerNorth Carolina Medicaid

PolicyPartners Individual Rehabilitation, Coordination, and Support (IRCS) Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain an authorized practitioner service order before or on the day IRCS services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

H0217U5Procedure code

15 minUnit

10 hr/weekMaximum

2,080 unitsAnnual average

18+

Medical Necessity and Coverage Criteria

Adult Initial Admission

All criteria A–G must be met for admission to IRCS for adults age 18 and older.

Adult admission

Qualifying diagnosis and impairment: The individual has received a comprehensive clinical assessment and has a diagnosis of serious and persistent mental illness, including bipolar disorder, major depression, a psychotic-spectrum disorder, and/or substance use disorder; the illness or disorder interferes with functioning in living, working, and/or learning environments; and moderate to severe functional impairment interferes with three or more areas among daily living, personal relationships, school/work, and recreation.At least 3 functional areas
Criteria A–C.
Medical necessity and least restrictive care: Traditional basic services alone are not clinically appropriate to prevent deterioration, IRCS is the least restrictive level of care, and expected treatment benefits outweigh potential harm.Required
Criterion D.
Risk or functioning indicators
- Indicator 1: Functioning is below the level expected of typically developing individuals of the same age.Present
- Indicator 2: The individual is at risk of psychiatric hospitalization, homelessness, and/or isolation from social supports due to serious and persistent mental illness and/or substance use disorder.Present
- Indicator 3: The individual exhibits behaviors requiring repeated interventions by mental health, social services, and/or judicial systems.Present
- Indicator 4:
Expected benefit and service order: The individual is expected to benefit from IRCS, the identified needs would not be better met by another formal or informal system or support, and a service order is completed by an authorized practitioner before or on the day services are provided.Required
Criteria F–G.

Adult Continued Services

All criteria A–E must be met for continued IRCS services for adults age 18 and older.

Adult continued services

Functional improvement: The individual has shown improvement in at least two areas among daily living, personal relationships, school/work, and recreation, while continued IRCS remains appropriate and beneficial.At least 2 functional areas
Criterion C.
Treatment participation: The individual and others identified through the person-centered-plan process participate in creating the person-centered plan and discharge plan and actively participate in treatment; designated others and the treatment team agree on goals, objectives, and interventions.Required
Criterion D.

IRCS is not Medicaid reimbursable when provided in acute care hospitals, inpatient psychiatric hospitals, psychiatric residential treatment facilities (PRTFs), institutions or residential settings of any type with more than 16 beds, or recreational settings primarily used for play and leisure activities, such as parks and community recreation centers. Services must be delivered in a setting convenient for the member that provides an adequate therapeutic environment and protects privacy and confidentiality.

IRCS may not be billed concurrently with the following excluded services: ACTT, Psychosocial Rehabilitation Services, Partial Hospitalization, Day Treatment, Residential Treatment, Supervised Living, Intensive In-Home, Family Centered Treatment, Multisystemic Therapy, Young Adults in Transition, and High-Fidelity Wraparound. When IRCS is coordinated with Community Support Team or other services and providers, the person-centered plan must specify which goals and objectives IRCS will address.

Codes, Units, and Billing Parameters

IRCS Procedure CodeHCPCSCovered

H0217U5

Partners Individual Rehabilitation, Coordination, and Support Services

Alternative Service Payment ArrangementHCPCSCovered

H2017U5

IRCS alternative service procedure code used in the payment arrangement

Encounter Data ReportingModifier

H2017 with CR modifier

Recommended procedure code and modifier for encounter-data reporting

Unit Definition

Unit of service15 minutes per unit

Billing basisIRCS is billed in 15-minute units

Rate per unit$8.22 per unit

Minimum Delivery

Minimum deliveryAt least 1 unit per day

Weekly frequency5 days per week

Scheduling flexibility

Provider Requirements and Denial Risks

Prior Authorization

Required Service Order

Obtain an IRCS service order before or on the day services are provided. The order must be completed by a physician, licensed psychologist, physician assistant, or nurse practitioner acting within the practitioner’s scope of practice.

Prior Authorization

Person-Centered Plan Authorization

IRCS must be included on the member’s person-centered plan (PCP) to address identified individualized needs. The PCP must specify the planned documentation frequency and the number of hours of IRCS the participant is to receive.

The frequency and delivery mode must be determined by the member’s clinical need.
IRCS must be delivered at least 1 unit per day, 5 days per week, and may be provided on weekends or in the evening.
IRCS is limited to a maximum of 10 hours per week, delivered over no more than 5 days per week.

Service Background

Individual Rehabilitation, Coordination, and Support (IRCS) is a psychiatric rehabilitation and community-support service—not psychotherapy or counseling. It is a strengths-based, person-centered skill-building service that helps members practice and reinforce illness self-management, daily living, interpersonal, vocational, coping, recovery, and community-integration skills. Services are individualized to the member’s diagnostic and clinical needs and are provided in natural settings, including the home and community, to support independence, stability, and functioning in living, learning, social, and work environments.

IRCS may include individualized skill building, recovery support, development of natural supports, and coordination with other services. Service intensity is expected to be greater early in treatment and decrease as the member develops skills and stability.

Key Definitions

Individual Rehabilitation, Coordination, and Support (IRCS)

Service nameIndividual Rehabilitation, Coordination, and Support (IRCS)

PurposeEnhance, restore, and/or strengthen skills needed to promote and sustain independence and stability

Service typeA skill-building service, not psychotherapy or counseling

Functional environmentsLiving, learning, social, and work environments

Natural Setting

Natural settingThe individual's home and community environments

Examples

Level of Care

Treatment Modality

Individual Rehabilitation, Coordination, and Support

IRCS is covered when all of the following treatment-modality requirements are met.

IRCS delivery model: IRCS must be strengths-based, person-centered, directly related to the individual's diagnostic and clinical needs, delivered in natural settings, and focused on practicing and reinforcing illness self-management, daily living, interpersonal, vocational, coping, recovery, and community-integration skills.Required

IRCS is a skill-building, rehabilitation, coordination, and community-support service rather than psychotherapy or counseling.

Service Limits and Utilization

IRCS Visit Limits

Minimum frequencyAt least 1 unit per day

Weekly schedule5 days per week

Maximum amount10 hours per week

IRCS Annual Utilization

Average utilization2,080 units per individual

Measurement periodPer 12 months

ServiceIndividual Rehabilitation, Coordination, and Support (IRCS)

Policy Summary

PayerNorth Carolina Medicaid

PolicyPartners Individual Rehabilitation, Coordination, and Support (IRCS) Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain an authorized practitioner service order before or on the day IRCS services are provided.

SourceLink

On This Page

The individual has impaired ability to recognize personal or environmental dangers and/or significantly inappropriate social behavior.

Services may be provided on weekends or in the evening

Maximum Delivery

Maximum delivery10 hours per week

Weekly schedule5 days per week

Planned hoursThe number of hours the participant receives must be specified in the Person-Centered Plan

Average Annual Utilization

Average annual utilization2,080 units per individual

Measurement periodPer 12 months

ServiceIndividual Rehabilitation, Coordination, and Support (IRCS)

Individual Staff Ratio

Individual deliveryProvided individually with one participant at a time

Staff ratioOne staff member to one participant

Service formatIndividual IRCS services

Virtual Group Staff Ratio

Virtual group deliveryIRCS may be provided in small groups using audio-visual equipment

Staff ratioOne staff member to eight adult participants (1:8)

Participant populationAdult participants

Denial Risk

Basic Services Alone Are Insufficient

Traditional basic services alone must not be clinically appropriate to prevent the individual’s condition from deteriorating. The clinician must determine that IRCS is the least restrictive level of care and that the treatment benefits outweigh potential harm.

Basic services include individual, family, or group therapy and medication management.

Documentation Required

Required Service-Note Content

Complete a service note for every contact with the individual. Documentation must show why IRCS was needed and how the intervention addressed the member’s individualized needs.

Describe the intervention provided.
Document the member’s response to the intervention.
Document progress toward the goals and objectives identified in the PCP.
Clearly reflect the specific need of the individual and the therapeutic interventions and supports rendered.

Documentation Required

Staff Signature and Contact Documentation

The qualified staff member who provides IRCS is responsible for completing and signing the service note. The note must identify the specific PCP goal or goals addressed by the contact.

Document each contact with the individual.
Include the staff member’s signature.
Identify the specific PCP goals addressed.

Billing Rule

Plan and Coordination Requirements

Ensure the PCP and related treatment documentation support the authorized hours, goals, objectives, interventions, and coordination of care. The PCP must identify which goals and objectives IRCS will treat when services are provided alongside other services or providers.

Document the number of IRCS hours in the member’s PCP.
Ensure individuals and others identified through the PCP process participate in creating the person-centered plan and discharge plan and actively participate in treatment.
Document agreement among designated others and the treatment team regarding treatment goals, objectives, and interventions.
Coordinate IRCS with other services and providers.

Denial Risk

Failure to Meet Adult Admission Criteria

Do not admit an adult to IRCS unless all admission criteria A–G are met and documented. Admission is unsupported when any required criterion is absent, including the required clinical assessment and diagnosis, functional impairment, lack of sufficient basic services, expected benefit, or timely service order.

The individual must be age 18 or older and have a comprehensive clinical assessment documenting SPMI and/or SUD within the qualifying diagnostic scope.
Symptoms must interfere with functioning, and moderate-to-severe impairment must affect at least three areas: daily living, personal relationships, school/work, or recreation.
The individual must meet at least three specified risk or functioning criteria.
The individual must be expected to benefit, and needs must not be better met by another formal or informal support system.
A qualifying service order must be completed by an authorized practitioner before or on the day services are provided.

Denial Risk

Failure to Meet Continued-Service Criteria

Continued IRCS is not supported unless all continued-service criteria A–E remain satisfied. Reassess and document ongoing eligibility, required scope and intensity, functional improvement, active participation, continued benefit, and the unmet outcome identified in the PCP.

The individual must continue to meet the admission criteria.
Provider documentation must show the scope and intensity of services required to meet program goals.
The individual must improve in at least two functional areas and be expected to continue benefiting from IRCS.
The individual, identified others, and treatment team must actively participate in the PCP, discharge plan, and treatment, with agreement on goals, objectives, and interventions.
The desired outcome or level of functioning must not yet have been restored or sustained within the PCP timeframe.

Unsupported block type: denial_risk物цев

Billing Rule

Non-Reimbursable Places of Service

IRCS is not Medicaid reimbursable when provided in excluded places of service or in a setting that does not provide a convenient, adequate therapeutic environment protecting the member’s privacy and confidentiality.

Non-reimbursable settings include acute care hospitals; inpatient psychiatric hospitals; psychiatric residential treatment facilities (PRTFs); institutions and residential settings of any type with more than 16 beds; and recreational settings used primarily for play or leisure, such as parks and community recreation centers.

Documentation Required

Insufficient Service Documentation

Incomplete or nonspecific documentation creates a denial risk. Maintain the PCP, service order, and service notes in accordance with all NCDHHS requirements and ensure the record supports every billed contact.

IRCS must appear on the PCP with a specific planned documentation frequency and authorized hours.
Document every contact, including the intervention, member response, progress toward PCP goals and objectives, and the individualized need addressed.
The qualified staff member must complete and sign each service note and identify the PCP goal or goals addressed.
Documentation must support the required scope and intensity of services, clinical need, service delivery mode, and coordination with other providers.

School, work, neighborhood, and relationships

Service requirementIRCS must be provided in a natural setting

Functional purposeProvide opportunities to acquire and improve skills for adaptive and independent community functioning and integration

Person-Centered Plan (PCP)

Plan namePerson-Centered Plan (PCP)

Goals and objectivesSpecifies the beneficiary's rehabilitative goals and objectives

Service frequencySpecifies the frequency of services

Treatment outcomesSpecifies expected treatment outcomes

Hours of serviceSpecifies the number of hours the participant receives IRCS services