Procedures and Practices for Referring Clients to Crisis Services (Non-Kaiser)

This article provides an overview of referring a client during a crisis situation including Rula’s procedure, best clinical practices, when to refer a client to emergency services, as well as how to document and bill for these situations. 

How Rula Responds to Client Crisis

Rula has a dedicated crisis hotline number staffed 24/7 with professional crisis support counselors. If a person contacts the Support or Scheduling Team during a mental health crisis, a team member will:

1. Engage with and encourage the client to seek help immediately.
2. Connect them with Rula's crisis hotline.
3. Notify the client’s Rula provider(s) of the situation; direct back the client to their provider for assessing the client's level of risk and following best practices.

Best Clinical Practices for Providers

As a provider who is assessing and managing a client in crisis, you’re encouraged to adhere to best practices and take the following action(s) as needed:

• All clients should be provided with emergency crisis resources from their provider during the first appointment and if/as requested throughout treatment. These resources may be used in the event of a behavioral health or psychiatric emergency. Providers should document the resources provided to the client.
  • Note: Providers can give clients Rula's crisis hotline phone number, +1 (877) 371-5488, as a resource for clients to call during a mental health crisis.
• Assess the client’s level of risk
• Contact 911 or the Suicide & Crisis Lifeline: 988. Additional hotline resources are available at SpeakingOfSuicide.com/resources

Some states may have specific requirements for how therapists and/or prescribers should handle a crisis, so make sure you check your local guidelines.

When to Refer to Crisis Services/First Responders

It’s important to recognize, assess, and have resources available for the two types of crises a client may encounter:

1. Emergent Medical Crisis: The individual is experiencing medically related injury (e.g. heart attack, severe wounds) 
   • Action → Contact 911/First responders
2. Emergent Mental Health Crisis: Behavioral health-related crisis can be identified whenever an individual places themself or others at immediate risk/self-harm; behavior/episode of behavior becomes severe and/or can’t be easily de-escalated (i.e. active suicidal or homicidal ideations with intent, acute psychosis, alcohol & drug withdrawal delirium) 
   • Action → Assess for level of risk (if possible) → Contact 911/First responders and/or 988

Rula’s Clinical Quality staff recognizes there are situations in which clients who are identified as high-risk might be best served in an in-person or higher-level of care environment if their needs are not being met effectively through individual counseling or routine outpatient psychiatry services. Please reference the help center article Determining Appropriateness for Telehealth before considering transferring a client outside of Rula due to high-risk needs.

How to Document & Bill for Crisis Situations

Coding

CPT manual recommends using codes 90839 (Psychotherapy crisis) and 90840 (Psychotherapy for Crisis add-on) to document emergency sessions with clients who are in high distress and under complex and/or life-threatening circumstances that demand immediate attention. For more information regarding CPT coding & covered services, see HERE.

Billing to insurance

Good to know:

• 90839 is billed for the first 60 minutes of a session (though it can be used for 30-74-minute sessions) and 90840 is billed for each additional 30 minutes. If you’re using both of these codes together, it requires the session to last 75 minutes or longer. 
• 90840 is an add-on code that must be used in conjunction with 90839. Note that there may be payer limitations to using 90840 (e.g. how many times per day it can be used)
• If you don't meet the time required to bill one or both of these two crisis codes, you can bill the standard CPT code for the session (e.g. 90837, individual psychotherapy, 30 minutes)
• 90839 can only be reported once per day although the time does not need to be continuous
• Be sure to check your state/local guidelines regarding the use of these codes on a monthly or annual basis, depending on where you provide service. 
• 90839 and 90840 can’t be used in conjunction with the following therapy codes:

• • 90791 and 90792 (initial evaluations/assessments)
  • 90832, 90834, and 90837 (psychotherapy)
  • 90875 (interactive complexity)

Documentation

Please understand that if you’re indicating/documenting “crisis” anywhere in a client’s chart the expectation of taking action (i.e. completing a risk assessment, safety plan, involving emergency responders) are expected of you and should not be referred to Care Coordination. Following the steps in the therapist H.E.L.P. system can ensure that you are following all steps to ensure a client’s safety. Click HERE to ensure you’re following best practices, complying with State licensure regulations, and ensuring your client’s safety to the best of your ability.

Always ensure the below information is clearly stated and easy to identify:

• Any risk assessment,
• Any recent referrals to a higher level of care of adjunct mental health services (if applicable)
• Collateral contact communication with anyone who may have pertinent information for the assessment (i.e. emergency contact, guardian)
• Any history of or recent substance use/abuse (if applicable)
• Outcome of the most recent session
• One of the common presentations for crisis intervention is suicidal ideation (SI). The SAFE-T is a valuable resource for assessing SI though many others are available as well. 

For examples of documenting a crisis situation, please see HERE.

Additional Resources

• Step Down Care
• Referring for In Person