Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 433.000 - Physician Services
Section 433.428 - Psychiatric Services: Introduction
Universal Citation: 130 MA Code of Regs 130.433
Current through Register 1531, September 27, 2024
(A) Covered Services. The MassHealth agency pays a physician or a psychiatric clinical nurse specialist (PCNS) for the psychiatry services described in 130 CMR 433.428 and 130 CMR 433.429.
(B) Non-covered Services.
(1)
Nonphysician and Non-PCNS Services. Except as
permitted in Section 603 of Subchapter 6 of the Physician
Manual, the MassHealth agency does not pay a physician or PCNS for
services provided by a social worker, psychologist, or other nonphysician
mental health professional employed or supervised by the physician or
PCNS.
(2)
Research and
Experimental Treatment. The MassHealth agency does not pay for
research or experimental treatment. This includes, but is not limited to, any
method not generally accepted or widely used in the field, or any session
conducted for research rather than for a member's clinical need.
(3)
Nonmedical
Services. The MassHealth agency does not pay a physician or PCNS
for nonmedical services including, but not limited to, the following:
(a) vocational rehabilitation
services;
(b) educational
services;
(c) recreational services
(play therapy, the use of play activities with a child in an identified
treatment setting as an alternative to strictly verbal expression of conflicts
and feelings, is not considered a recreational service and is
payable);
(d) street-worker
services (information, referral, and advocacy to certain age populations;
liaison with other agencies; role modeling; and community organization);
(e) life-enrichment services
(ego-enhancing services such as workshops or educational courses provided to
functioning persons); and
(f)
biofeedback.
(4)
Nonmedical Programs. The MassHealth agency does not
pay for diagnostic and treatment services that are provided as an integral part
of a planned and comprehensive program that is organized to provide primarily
nonmedical or other non-covered services. Such programs include freestanding
alcohol or drug detoxification programs, freestanding methadone maintenance
programs, residential programs, day activity programs, drop-in centers, and
educational programs.
(5)
Psychological Testing. The MassHealth agency does not
pay for psychological testing provided by a physician or a PCNS.
(C) Services Provided by a Psychiatric Clinical Nurse Specialist (PCNS).
(1)
General. 130 CMR
433.428 and
130 CMR
433.429 apply specifically to physicians and
psychiatric clinical nurse specialists. In general however, subject to
compliance with state and federal law, the requirements and limitations
elsewhere in 130 CMR 433.000 that apply to a physician, also apply to a
psychiatric clinical nurse specialist (PCNS), such as service and payment
limitations, recordkeeping and reporting requirements, and prior authorization
and other conditions of coverage.
(2)
Conditions of
Payment. The MassHealth agency pays a PCNS or group practice for
PCNS services when
(a) the services are
limited to the scope of practice authorized by state law or regulation
(including, but not limited to, 244 CMR: Board of Registration in
Nursing or of the state licensing agency of another state in which the
services are provided);
(b) the PCNS
or group practice is not an employee of the hospital or other facility in which
the PCNS services were performed, or is not otherwise paid by the hospital or
facility for the service;
(c) the
PCNS participates in MassHealth pursuant to the requirements of 130 CMR
433.428(C)(3); and
(d) for an
out-of-state PCNS, the requirements of
130 CMR 433.403(C)
are met.
(3)
PCNS Provider
Eligibility. Any PCNS applying to participate as a provider in
MassHealth must submit documentation, satisfactory to the MassHealth agency,
that he or she
(a) is licensed to practice as
a PCNS by the Massachusetts Board of Registration in Nursing or by the
licensing agency of another state in which the PCNS services are provided;
and
(b) is a member of a group
practice or is in a solo private practice.
(4)
Consultation Between a PCNS
and a Physician. The MassHealth agency does not pay for a
consultation between a PCNS and a physician as a separate service.
(D) Record Keeping (Medical Records) Requirements. In addition to the provisions in 130 CMR 433.409, the following specific information must be included in the medical record for each member receiving psychiatric services:
(1) the condition or reason for
which psychiatric services are provided;
(2) the member's diagnosis;
(3) the member's medical history;
(4) the member's social and occupational
history;
(5) the treatment
plan;
(6) the physician's or PCNS's
short- and long-range goals for the member;
(7) the member's response to treatment;
and
(8) if applicable, a copy of
the signed consent for electroconvulsive therapy.
(E) Frequency of Treatment. The MassHealth agency pays a physician for only one session of each type of service provided to a member in one week except for crisis intervention, as described below.
(1)
In a crisis, as defined in
130 CMR
433.429(K), the MassHealth
agency will pay a physician for extra sessions. The physician must bill for
these services using the service code for crisis intervention and must document
the following in the member's record:
(a) the
member is in a state of marked life change or crisis;
(b) the member's ability to function is
likely to deteriorate; and
(c) the
plan of treatment is to resume or to initiate regular weekly sessions after the
resolution of the crisis.
(2) Although prior authorization is still
required after 17 treatment sessions, the MassHealth agency will pay a
physician for more than one type of service provided to a member in one week if
the additional service or services are medically necessary. The member's record
must document the circumstances necessitating the provision of more than one
type of service. The record must make clear that the substitution of one type
of service for another would not adequately benefit the member and that an
additional type of service is necessary.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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