Current through Register Vol. 56, No. 18, September 16, 2024
(a) Mental health
services shall include comprehensive intake evaluation, individual
psychotherapy, off-site crisis intervention, family therapy, family conference,
group psychotherapy, psychological testing, partial care, and medication
management. Mental health services shall not include:
1. Student education, including preparation
of school-assigned classwork or homework; or
2. Incentive programs, including, but not
limited to, non-therapeutic token economies and subcontract work
responsibilities.
(b)
Only one type of mental health service per beneficiary shall be reimbursable to
an independent clinic per day, with the following exceptions:
1. Medication management may be reimbursed
when provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary in
addition to one of the following mental health services: assessment, individual
psychotherapy, group psychotherapy, family therapy, and family
conference.
2. Individual, group,
or family psychotherapy services may be provided on the same date of service,
but are limited to one unit each of individual psychotherapy, group
psychotherapy, family therapy, or family conference. A maximum of three
individual or group psychotherapy sessions may be provided per day, but are
limited to five units per week. The provision of multiple services in one day
is meant to supplant the need for partial care services and may not be billed
on the same date of service as partial care.
3. An assessment may be completed on the same
date of service as individual, group, or family therapy, but shall count toward
the total of three units per day and five units per week.
4. Evaluation and management by a physician
or APN may be provided concurrently with assessment or psychotherapy services
and shall not count toward the total of three units per day or five units per
week.
(c) Mental health
clinics shall provide mental health services by, or under the direction of, a
psychiatrist.
(d) For purposes of
partial care, full day means five or more hours of participation in active
programming exclusive of meals, breaks and transportation; half day means at
least three hours but less than five hours of participation in active
programming exclusive of meals, breaks and transportation. The smallest unit of
partial care that may be prior authorized by NJ Medicaid/FamilyCare is one
hour, with a minimum of two hours per day and a maximum of five hours per day.
For example, prior authorization for a full day of partial care (five hours)
shall be reflected as five units, four hours shall be reflected as four units,
a half day (three hours) shall be reflected as three units, and two hours shall
be reflected as two units. Additional details are located at N.J.A.C.
10:66-6.
(f) The Division shall reimburse a provider
for prevocational services provided within the context of a partial care
program. Prevocational services shall be interventions, strategies, and
activities, within the context of a partial care program, that assist
individuals to acquire general work behaviors, attitudes, and skills needed to
take on the role of worker and in other life domains, such as responding
appropriately to criticism, decision making, negotiating for needs, dealing
with interpersonal issues, managing psychiatric symptoms, and medication
adherence. Services or interventions which are not considered prevocational
will not be reimbursed by the Medicaid and NJ FamilyCare programs. Examples of
services or interventions not considered to be prevocational include:
1. Technical or occupational skills
training;
2. College
preparation;
3. Student education,
including preparation of school-assigned classwork or homework; and
4. Individualized job development.
(g) The Division will not
reimburse any provider for vocational services provided within the context of a
partial care program.
1. Vocational services
shall be those interventions, strategies, and activities that assist
individuals to acquire skills to enter a specific occupation and take on the
role of colleague, that is, a member of a profession, and/or assist the
individual to directly enter the workforce and take on the role of an employee,
working as a member of an occupational group for pay with a specific
employer.
(h) When, in
the judgment of the treatment team, an individual is determined appropriate for
discharge or referral to another employment-related service provider or
situation, and has demonstrated mastery of individualized goals and objectives,
such as: an ability to respond appropriately to criticism, make decisions,
negotiate for needs, deal with interpersonal issues, manage psychiatric
symptoms and adhere to medical prescriptions, the service provider shall:
1. Update the individual treatment
goal;
2. Revise the discharge plan;
and
3. Refer the individual to a
community work setting, if such referral is appropriate for the
individual.
(i) The
Division will reimburse a provider for prevocational services provided to
eligible beneficiaries within the context of a partial care program when the
services consist of therapeutic subcontract work activity, and when all of the
following requirements are met:
1. The
therapeutic subcontract work activity shall consist of production, assembly
and/or packing/collating tasks for which individuals with disabilities
performing these tasks are paid less than minimum wage, and, pursuant to 29
C.F.R. § 525, a special minimum wage certificate has been issued to the
organization/program by the U.S. Department of Labor;
2. The individual's plan of care shall
contain a stipulation that the therapeutic subcontract work activity is a form
of intervention intended to address the individual deficits of the patient as
identified in the client's assessment;
3. The therapeutic subcontract work activity
shall be facilitated by a qualified mental health services worker;
4. The therapeutic subcontract work activity
shall be performed within the line of sight of the qualified mental health
services worker; and
5. The staff
to client ratio shall not exceed a ratio of 1:10 qualified mental health
services worker to client.
(j) An intake evaluation shall be performed
within 14 days of the first encounter or by the third clinic visit, whichever
is later, for each beneficiary being considered for continued treatment. This
evaluation shall consist of a written assessment that:
1. Evaluates the beneficiary's mental
condition;
2. Determines whether
treatment in the program is appropriate, based on the beneficiary's
diagnosis;
3. Includes
certification, in the form of a signed statement, by the evaluation team, that
the program is appropriate to meet the beneficiary's treatment needs;
and
4. Is made part of the
beneficiary's records.
5. The
evaluation for the intake process shall include a physician or an advanced
practice nurse (APN) and an individual experienced in the diagnosis and
treatment of mental illness. Both criteria may be satisfied by the same
individual, if appropriately qualified.
(k) A written, individualized plan of care
shall be developed for each beneficiary who receives continued treatment. The
plan of care shall be designed to improve the beneficiary's condition to the
point where continued participation in the program, beyond occasional
maintenance visits, is no longer necessary. The plan of care shall be included
in the beneficiary's records and shall consist of:
1. A written description of the treatment
objectives including the treatment regimen and the specific medical/remedial
services, therapies, and activities that shall be used to meet the objectives.
i. Due to the nature of mental illness and
the provision of program services, there may be instances in which a temporary
deviation from the services written in the treatment plan occurs. In this
event, the client may participate in alternate programming. The reason for the
deviation should be clearly explained in the daily or weekly documentation.
Deviations that do not resolve shall require a written change in the treatment
plan;
2. A projected
schedule for service delivery which includes the frequency and duration of each
type of planned therapeutic session or encounter;
3. The type of personnel that will be
furnishing the services; and
4. A
projected schedule for completing reevaluations of the beneficiary's condition
and updating the plan of care.
(l) The mental health clinic shall develop
and maintain legibly written documentation to support each medical/remedial
therapy service, activity, or session for which billing is made.
1. This documentation, at a minimum, shall
consist of:
i. The specific services
rendered, such as individual psychotherapy, group psychotherapy, family
therapy, etc., and a description of the encounter itself. The description shall
include, but is not limited to, a statement of patient progress noted,
significant observations noted, etc.;
ii. The date and time that services were
rendered;
iii. The duration of
services provided;
iv. The
signature of the practitioner or provider who rendered the services;
v. The setting in which services were
rendered; and
vi. A notation of
unusual occurrences or significant deviations from the treatment described in
the plan of care.
2.
Clinical progress, complications and treatment which affect prognosis and/or
progress shall be documented in the beneficiary's medical record at least once
a week, as well as any other information important to the clinical picture,
therapy, and prognosis.
3. The
individual services under partial care shall be documented on a daily basis.
More substantive documentation, including progress notes and any other
information important to the clinical picture, are required at least once a
week.
(m) Periodic
review of the beneficiary's plan of care shall take place at least every 90
days during the first year and every six months thereafter.
1. The periodic review shall determine:
i. The beneficiary's progress toward the
treatment objectives;
ii. The
appropriateness of the services being furnished; and
iii. The need for the beneficiary's continued
participation in the program.
2. Periodic reviews shall be documented in
detail in the beneficiary's records and made available upon request to the New
Jersey Medicaid or NJ FamilyCare program or its agents.
(n) When requesting reimbursement for the
following HCPCS procedure codes for rehabilitative services, a separate service
line shall be completed for each day that the service is provided. Providers
shall not "span bill" for services.
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