Current through September 17, 2024
Note: All requirements in 471 NAC
20-001 apply to outpatient
psychiatric services.
002.01
Covered Outpatient Psychiatric Therapeutic Services
Nebraska Medical Assistance Program covers the following
outpatient psychiatric therapeutic services for clients age 21 and older as
defined in 471 NAC 20-001.12:
1.
Psychiatric evaluation;
2.
Psychological evaluation;
3.
Psychological testing;
4.
Individual Psychotherapy;
5. Group
Psychotherapy (a group overview must be approved by Medicaid prior to billing
for this service);
6. Family
Psychotherapy Services;
7. Family
Assessment;
8. Medication checks by
a physician or a physician extender;
9. Electroconvulsive Therapy.
Treatment for chemical dependency is not covered for clients
age 21 and older.
Skilled nursing services for the monitoring of medications is
available through Home Health Agencies (see 471 NAC 9-000).
002.02
Psychiatric
Therapeutic Staff Standards
The following psychiatric therapeutic staff may provide
services and must meet the requirements as defined in 471 NAC 20-001.13
-
1. Physician;
2. Licensed Psychologist;
3. Physician extenders;
4. Licensed Independent Mental Health
Practitioner;
5. Allied Health
Therapists.
20-002.02A
Location of Services: Outpatient psychiatric services
by qualified staff may be provided in -
1. A
licensed community mental health program which meets the criteria for approval
by the Joint Commission on Accreditation of Healthcare Organizations, CARF,
COA, or AOA;
2. A licensed and
certified hospital which provides psychiatric services and which -
a. Is maintained for the care and treatment
of patients with primary psychiatric disorders;
b. Is licensed or formally approved as a
hospital by the Nebraska Department of Health and Human Services, Division of
Public Health, or if the hospital is located in another state, the officially
designated authority for standard -setting in that state;
c. Is accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or AOA;
d. Has licensed and certified psychiatric
beds;
e. Meets the requirements for
participation in Medicare for psychiatric hospitals; and
f. Has in effect a utilization review plan
applicable to all Medicaid clients;
3. A licensed and certified hospital which
provides acute medical services and which -
a. Is maintained for the care and treatment
of patients with acute medical disorders;
b. Is licensed or formally approved as a
hospital by the Nebraska Department of Health and Human Services, Division of
Public Health, or if the hospital is located in another state, the officially
designated authority for standard -setting in that state;
c. Is accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or AOA;
d. Meets the requirements for participation
in Medicare for acute medical hospitals; and
e. Has in effect a utilization review plan
applicable to all Medicaid clients;
4. A physician's private office;
5. A licensed psychologist's private
office;
6. An allied health
therapist's private office;
7. The
client's home;
8. Nursing homes;
or
9. Rural Mental Health Clinics
or Federally Qualified Health Centers.
Therapy is not reimbursable in any other location.
002.03
Provider
Agreement
A provider of psychiatric outpatient services shall complete
a provider agreement, and submit the form to the Department for
approval:
1. Independent psychiatric
service providers (physicians, licensed psychologists) shall complete Form
MC-19, "Medical Assistance Provider Agreement." The provider agreement issued
to the supervising practitioner (or clinic) is used to claim services provided
by allied health therapists who are in his/her employ or supervision. For
outpatient psychiatric services provided through a group practice, the Provider
Agreement must be kept current by providing the Department with:
a. The termination date of any therapist
leaving the group practice;
b. The
initial employment date of any therapist joining the group practice;
c. A current resume detailing education and
clinical experience for each application for allied health
therapists.
2. Hospitals
as defined in 471 NAC 20-002.02A providing outpatient psychiatric services
shall complete Form MC-20, "Medical Assistance Hospital Provider Agreement."
Providers are responsible for verifying that allied health
therapists, physicians, physician extenders, and licensed psychologists are
appropriately licensed for the correct scope of practice.
20-002.03A
Geographically-Deprived Areas: A
geographically-deprived area is an area where a psychiatrist is not available
in the community, or within a reasonable driving distance of the community, to
provide services. A physician who is qualified, skilled, and experienced in the
diagnosis and treatment of psychiatric disorders may serve as an alternative to
a psychiatrist for outpatient services in a geographically-deprived area. A
resume detailing the physician's mental health education and experience must
accompany the provider agreement. When outpatient psychiatric services are
provided under these conditions, the physician is subject to all policy
requirements outlined for psychiatrists. Psychiatric services provided by the
attending physician, other than a psychiatrist, are limited to the following:
Psychotherapy services provided in a physician's office which
do not exceed six months without documented consultation between the physician
providing the service and a psychiatrist.
002.04
Coverage Criteria for
Outpatient Psychiatric Services
The Nebraska Medical Assistance Program covers outpatient
psychiatric therapeutic services listed in 471 NAC 20002.01 when the services
are medically necessary and provide active treatment as defined in 471 NAC
20-001.15 and 20-001.16.
Medical necessity and active treatment for outpatient
services is documented through the use of the Department's approved treatment
planning document (471 NAC 20-002.06) which must be developed by a licensed
practitioner and supervising practitioner based on a thorough evaluation of the
client's restorative needs and potentialities for a primary psychiatric
diagnosis.
20-002.04A
Services Provided by Allied Health Therapists:
Services provided by Allied Health Therapists (as defined in 471 NAC 20-001.13)
must be prescribed and provided under the direction of a supervising
practitioner. Supervision must meet the active treatment criteria in 471 NAC
20-001.16.
Definition and Practice of
Supervision: Supervision by the supervising practitioner is
defined as the critical oversight of a treatment activity or course of action.
This includes, but is not limited to, review of treatment plan and progress
notes, client specific case discussion, periodic assessments of the client
(annually, or more often if necessary), and diagnosis, treatment intervention
or issue specific discussion. The supervising practitioner is a source of
information and guidance for all members of the treatment team and their
participation in services as an essential ingredient for all members of the
treatment. The critical involvement of the supervising practitioner must be
reflected in the Initial Diagnostic Interview, the treatment plan, and the
interventions provided.
The supervising practitioner (or their designated and
qualified substitute) must be available, in person or by telephone, to provide
assistance and direction as needed during the time the services are being
provided.
Supervisory contact may occur in a group setting.
Supervision is not billable by either the therapist or the
supervising practitioner as it is considered a mandatory component of the
care.
Psychiatric resident physicians and physician extenders may
not supervise allied health therapists for Medicaid services.
The supervising practitioner shall periodically evaluate the
therapeutic program and determine if treatment goals are being met and if
changes in direction or emphasis are needed.
The supervising practitioner must personally re-evaluate the
client through a face-to-face contact annually or more often, if
necessary.
002.05
Initial Diagnostic Interview
Before a client is accepted for treatment, an Initial
Diagnostic Interview must be completed.
The supervising practitioner must evaluate the client within
four weeks of the initial contact with the therapist, or sooner if necessary.
If the client does not continue with therapy sessions past the fourth session
or does not attend the assessment session with the supervising practitioner,
the therapist must review the specific case with the supervising practitioner,
to establish a diagnosis and confirm that the interventions were appropriate.
For clients continuing in therapy, reimbursement will not be available for more
than four sessions until the client is assessed by the supervising
practitioner.
002.06
Treatment Planning
When treatment is initiated, the provider shall work with
the client and family (at the client's discretion) to develop the treatment
plan. If the client is accepted for treatment, the treatment plan must be
completed within two sessions of the assessment by the supervising practitioner
and is based on the following:
1. The
client must have sufficient need for active psychiatric treatment at the time
the psychiatric service provider accepts the client; and
2. The treatment must be the best choice for
expecting reasonable improvement in the client's psychiatric condition.
The goals and objectives documented on the treatment plan
must reflect the recommendations from the Initial Diagnostic Interview, the
supervising practitioner and the therapist. The treatment interventions
provided must reflect these recommendations, goals, and objectives. Evaluation
of the treatment plan by the therapist and the supervising practitioner should
reflect the client's response to the treatment interventions based on the
recommendations, goals and objectives.
The provider must document their attempts to involve the
family in treatment plan development and treatment plan reviews. A variety of
communication means should be considered. These may include, but should not be
limited to, including the family via conference telephone calls, using
registered letters to notify the family of meetings, and scheduling meetings in
the evening and on weekends.
Providers must be available to schedule meetings and sessions
in a flexible manner to accommodate and work with a family's schedule. This
includes the ability to schedule sessions at a variety of times including
weekends or evenings.
Providers must encourage family members to be involved in the
assessment of the client, the development of the treatment plan, and all
aspects of the client's treatment unless prohibited by the client, through
legal action, or because of federal confidentiality laws.
20-002.06A
Treatment Planning
Document Update: The treatment plan must be reviewed and updated
every 90 days, or more frequently if indicated. The client's clinical record
must include the supervising practitioner's comments on the client's response
to treatment and changes in the treatment plan. The supervising practitioner
must review and sign off on the updated treatment plan prior to its initiation.
Changes in the treatment plan must be noted on the current treatment planning
document. In addition, the psychiatric service provider shall complete an
updated treatment planning document annually, or more frequently if necessary,
to reflect changes in treatment needs. A copy of the current treatment planning
document must be maintained in the client's medical record.
For services provided under the supervision of a supervising
practitioner, the signature of the supervising practitioner on the treatment
planning document indicates his/her agreement that the scheduled treatment
interventions are appropriate.
002.07
Documentation in Client's
Clinical Records
All documents submitted to Medicaid must contain sufficient
information for identification (i.e., client's name, dates, and time of
service, provider's name). Documentation must be legible. The client's medical
record must also include -
1. The
Initial Diagnostic Interview;
2.
The treatment plan, (including the initial document, updates, and
current);
3. The client's
diagnosis. A provisional or interim psychiatric diagnosis must be established
by the supervising practitioner at the time the client is accepted for
treatment. This diagnosis must be reviewed and revised as a part of the
treatment plan;
4. A chronological
record of all psychiatric services provided to the client, the date performed,
the duration of the session, and the staff member who conducted the
session;
5. A chronological account
of all medications prescribed, the name, dosage, and frequency to be
administered and client's response;
6. A comprehensive family
assessment;
7. A clear record of
family and community involvement;
8. Documentation verifying coordination with
other therapists when more than one provider is involved with the
client/family; and
9.
Transition/discharge planning.
002.08
Transition/Discharge
Planning Services
Providers of outpatient psychiatric services shall meet the
transition/discharge planning requirements noted in 471 NAC
20-001.18.
002.09
Utilization Review
Payment for outpatient psychiatric services is based on
adequate legible documentation of medical necessity and active treatment. All
outpatient claims are subject to utilization review before payment. Illegible
documentation may result in denial of payment (see 471 NAC 20-001.19).
Additional documentation from the client's clinical record
may be requested prior to considering authorization of payment when the
treatment plan does not adequately document medical necessity or active
treatment.
002.10
Guidelines for Specific Services
20-002.10A
Psychological Testing
and Evaluation Services: Testing and evaluation services must
reasonably be expected to contribute to the diagnosis and plan of care
established for the individual client. Medical necessity must be documented.
Testing and evaluation services may be performed by a
licensed psychologist, or by a specially licensed psychologist or a master's
level person approved to administer psychological testing under the supervision
of a licensed psychologist.
If testing and evaluation services are provided by a
licensed, non-certified psychologist, the services must be ordered by a
supervising practitioner. The treatment plan must be signed by the supervising
practitioner.
A copy of the testing narrative summary must be kept in the
client's clinical record. If the evaluation is court ordered, the provider
shall note this on the treatment plan and include documentation of medical need
for the service. Payment is made according to the Nebraska Medicaid
Practitioner Fee Schedule.
20-002.10B
Grandparented Masters
Psychologists: Services provided by master's level clinical
psychologists whose certification has been grandparented by the Department of
Health and Human Services, Division of Public Health may be covered under 471
NAC 20002 ff. Documentation of the grandparented status may be
required.
20-002.10C
Medication Checks: Medication checks may only be done
when medically necessary. When a physician provides psychotherapy services,
medication checks are considered a part of the psychotherapy service.
The supervising physician may provide a medication check when
a licensed psychologist or an allied health therapist provides the
psychotherapy service. Only physicians and psychiatrically trained physician
extenders may provide medication checks.
20-002.10D
After-Care: After-care as defined by the American
Psychiatric Association is a complex system of services including, but not
limited to, psychotherapy, medication checks, and social, rehabilitative, and
educational services required and necessary to deinstitutionalize the chronic
patient who has undergone extended hospital treatment and care. This "service
package" does not meet the criteria of active treatment and is not covered by
the Nebraska Medical Assistance Program. Individually-identified services may
be claimed under the appropriate HCPCS/CPT procedure code and are subject to
the active treatment standard.
20-002.10E
Professional and
Technical Components for Hospital Diagnostic and Therapeutic
Services: For regulations regarding professional and technical
components for diagnostic and therapeutic hospital services, the elimination of
combined billing, and non-physician services and items provided to hospital
patients, refer to 471 NAC 10-003.05C, 10-003.05D, 10-003.05E, and
10-003.05F.
20-002.10F
Travel to the Home of Individuals Who Have Handicaps:
If a client has a handicapping physical condition that prevents them from
traveling to a mental health clinic or office, the provider may request prior
authorization to bill for mileage to the client's home. The following
requirements must be met:
1. The provider
requests prior authorization before the initiation of services;
2. The treatment must meet the criteria for
active treatment and medical necessity;
3. The client's handicapping physical
condition prevents their travel to the mental health clinic or office;
and
4. The client's home is more
than 30 miles from the clinic or office.
This information must be provided, in writing, to the
Medicaid Central Office staff or their designee for consideration.
20-002.10G
Family Assessment: NMAP covers family assessments used
to identify the functional level of the family unit and the system changes that
would influence this functional level. This includes interviews with the client
and collateral parties.
002.11
Payment for Outpatient
Psychiatric Services
20-002.11A
Payment for Outpatient Psychiatric Services in a
Hospital: Payment for outpatient psychiatric services is made
according to Nebraska Medicaid Practitioner Fee Schedule. The Nebraska Medical
Assistance Program (NMAP) pays for covered outpatient mental health services,
except for laboratory services, at the lower of -
1. The provider's submitted charge;
or
2. The allowable amount for that
procedure code in the Medicaid Practitioner Fee Schedule for that date of
service. The allowable amount is indicated in the fee schedule as -
a. The unit value multiplied by the
conversion factor;
b. The maximum
allowable dollar amount; or
c. The
reasonable charge for the procedure as determined by the Division of Medicaid
and Long-Term Care (indicated as "BR" - by report or "RNE" -rate not
established in the fee schedule).
20-002.11B
Revisions of the Fee
Schedule: The Department reserves the right to adjust the fee
schedule to -
1. Comply with changes in state
or federal requirements;
2. Comply
with changes in national standard code sets such as HCPCS and CPT;
3. Establish an initial allowable amount for
a new procedure based on information that was not available when the fee
schedule was established for the current year; and
4. Adjust the allowable amount when the
Division of Medicaid and Long-Term Care determines that the current allowable
amount is -
a. Not appropriate for the
service provided; or
b. Based on
errors in data or calculation.
The Department may issue revisions of the Nebraska Medicaid
Practitioner Fee Schedule during the year that it is effective. Providers will
be notified of the revisions and their effective dates.
002.12
Billing Requirements
For outpatient psychiatric service providers, the following
requirements must be met.
1. Community
mental health programs providing outpatient psychiatric services shall submit
all claims for outpatient services on an appropriately completed Form CMS-1500
(see 471-000-64) or the standard electronic Health Care Claim: Professional
transaction (ASC X12N 837).
Payment for approved outpatient psychiatric services provided
by employees of a community mental health program is made to the
facility.
2. Hospitals
providing outpatient psychiatric services shall submit all claims for
non-physician services on an appropriately completed Form CMS-1450 or the
standard electronic Health Care Claim: Institutional transaction (ASC X12N
837).
All M.D. services shall be submitted on an appropriately
completed CMS-1500.
Payment for approved outpatient psychiatric services provided
by employees of a hospital is made to the facility.
3. Independent providers of outpatient
psychiatric services (psychiatrist or clinical psychologist in a private office
who is not an employee of a hospital or community mental health center) shall
submit all claims for outpatient psychiatric services provided in their private
office on an appropriately completed Form CMS-1500 (see 471-000-64) or the
standard electronic Health Care Claim: Professional transaction (ASC X12N 837).
Payment for approved outpatient psychiatric services provided
in an independent provider's private office is made to the provider as
identified on the provider agreement.
20-002.12A
Documentation for
Claims: For outpatient psychiatric services, unless otherwise
instructed by Medicaid or their designee, the following documentation must be
kept in the client's file for each claim:
1.
The initial treatment plan; or
2.
An updated version of the treatment plan completed every 90 days.
For psychological testing and evaluation services, unless
otherwise instructed by Medicaid, the following information must be kept in the
client's file:
1. The treatment
plan;
2. Medical necessity for the
service documented on the treatment plan;
3. The documentation that the evaluation
services will reasonably be expected to contribute to the diagnosis and plan of
care established for the individual client; and
4. A narrative of the testing
results.
002.13
Procedure Codes and Descriptions
HCPCS/CPT procedure codes used by NMAP are listed in the
Nebraska Medicaid Practitioner Fee Schedule (see 471-000-532).
