Current through Register Vol. 56, No. 18, September 16, 2024
(a) Federal legislation (1919 of the Social Security Act, 42 U.S.C. §
1396r) established Pre-Admission Screening and Resident Review (PASRR) (PAS) for MI/MR applicants to Medicaid/NJ FamilyCare-participating nursing facilities (NFs) and further reviews, as indicated by a significant change in a beneficiary's mental or physical condition, for residents of Medicaid/NJ FamilyCare-participating NFs.
(b) Through PASRR, NF applicants or residents of NFs are evaluated to assess the appropriateness of their admission to the facility or continued residence within the facility, in respect to whether they need specialized services for the treatment of mental illness or mental retardation. Persons in need of specialized services will be directed to an alternate placement.
(c) The initial Preadmission Screening (PAS) screening is conducted by professional staff designated by the New Jersey Department of Health and Senior Services (DHSS), to determine whether the individual requires nursing facility level of care.
1. After the professional staff designated by DHSS has determined that the individual meets the criteria for the NF-level of care, an individual identified as meeting the criteria for mental retardation services is referred to the staff of the Division of Developmental Disabilities for a specialized service evaluation.
2. An individual identified as meeting criteria for mental illness is evaluated by a psychiatrist, an attending physician or an APN who is certified in the advanced practice category of Psychiatric/Mental Health to determine the need for specialized services.
(d) Professionals who are qualified to perform psychiatric evaluations for PASRR include psychiatrists, general physicians, both doctors of medicine (M.D.) and of osteopathy (D.O.) and APNs who are certified in the advanced practice category of Psychiatric/Mental Health.
(e) The initial Pre-Admission PASRR Screen shall be used for Medicare and/or Medicaid and NJ FamilyCare--Plan A persons residing in the community (currently at home or boarding home) who are applicants to Medicare/Medicaid/NJ FamilyCare nursing facilities and are being examined by an attending-physician or APN, Psychiatric/Mental Health, to determine the need for specialized services for mental illness. Clinical practitioners completing the screen to determine the need for specialized services shall use the 99333 HCPCS procedure code with a Medicaid/NJ FamilyCare maximum fee allowance as listed in N.J.A.C. 10:58A-4.
1. If the screening examination reveals the need for a more specialized examination, a psychiatric consultation may be requested by the attending physician or APN, Psychiatric/Mental Health. Existing consultation codes for limited consultation and for comprehensive consultation may be used for this purpose by the consulting psychiatrist, as appropriate. Applicants with a diagnosis of MI or MR, regardless of the payment source of their care, shall be subject to the PASRR review. For MI individuals funded through other than the New Jersey Medicaid/NJ FamilyCare programs, the fee for psychiatric evaluations conducted by psychiatrists or in NFs by attending physicians or APN, Psychiatric/Mental Health will be paid by Medicare, other third party carriers or by the individual.
2. If the individual has a diagnosis of Alzheimer's disease or related dementia, as described in the 1987 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), documentation shall be provided to the admitting Medicaid/NJ FamilyCare-certified nursing facility, for the individual's clinical record, on the history, physical examination, and diagnostic work-up, to support the diagnosis. Dementia-diagnosed individuals shall have psychiatric disorders diagnosed and documented. (Neither a new examination nor a comprehensive neurological evaluation shall be required.) Individuals diagnosed as mentally retarded who are also diagnosed as having organic dementia shall be evaluated in accordance with the DDD Level II screens to determine need for specialized services.
i. The examining attending-physician or APN, Psychiatric/Mental Health shall obtain the "Division of Mental Health Services Psychiatric Evaluation" form from the nursing home administrator and shall fax the completed form to (609) 777-0662 or mail the form to the Division of Mental Health Services, PO Box 727, Trenton, New Jersey 08625-0727, Attention: PASRR Coordinator.
ii. The evaluation form shall be mailed no later than 48 hours following the consultation to prevent undue delay in patient placement.
(f) The HCPCS procedure codes and reimbursement amounts previously established by the Division for the Annual Resident Review of PASRR, shall be used for Medicare and/or Medicaid/NJ FamilyCare-Plan A nursing facility patients who are being evaluated by the attending physician or APN, Psychiatric/Mental Health, for the purposes of a resident review, the necessity of which was indicated by a significant change in the condition of the beneficiary, to determine the need for specialized services for mental illness.
1. If this examination reveals the need for a more specialized examination, a psychiatric consultation may be requested by the attending physician or APN, Psychiatric/Mental Health. Existing consultation codes for limited consultation and for comprehensive consultation may be used for this purpose by the consulting psychiatrist as appropriate.
2. If the individual has a diagnosis of Alzheimer's disease or related dementias, as described in the 1987 edition of the Diagnostic and Statistical Manual of Mental Disorders, once the original documentation has been obtained, that documentation supporting the diagnosis shall be kept on the resident's current clinical record. (A new examination does not have to be completed.)
3. The procedure can only be utilized on an annual basis by the same physician or APN, Psychiatric/Mental Health for the same patient.
i. The provider shall attach a completed Division of Mental Health Services Psychiatric Evaluation form (DMHS-1994) to the patient's clinical chart. The Nursing Facility administrator will be responsible for providing these forms to the attending physician or APN, Psychiatric/Mental Health.
ii. The attending physician or APN, Psychiatric/Mental Health will complete the psychiatric evaluation. The NF will submit a copy of the Psychiatric Evaluation to the MACC. The required annual resident review information shall be submitted to the MACC no later than the fifth day of the month in which the reassessments are due.
(g) As used in this section, a "significant change" is defined as a major change in a resident's condition that will not improve without intervention by appropriate staff, impacts on more than one area of the resident's health, mental health, and/or functioning, and requires interdisciplinary review or revision of the care plan.
