Current through Register Vol. 46, No. 39, September 25, 2024
(a) Medicaid claims for individuals who have
been admitted to a Mental Health Outpatient Treatment and Rehabilitative
Service program shall include, at a minimum, the Medicaid identification number
of the individual, the designated mental illness diagnosis, the procedure code
or codes corresponding to the procedure or procedures provided, the location of
the service, specifically the licensed location where the service was provided
or the clinician's regular assigned licensed location from which the clinician
departed for an off-site procedure, and the National Provider Identification or
equivalent Department of Health-approved alternative as appropriate of the
attending clinician. The provider must also comply with the requirements
associated with any procedure code being billed.
(b) Medicaid claims may be reimbursed for up
to three pre-admission procedures per adult individual, excluding Peer/Family
Support Services which has no pre-admission reimbursement limit, no more than
one of which may be a collateral procedure. For children, claims may be
reimbursed for up to three pre-admission visits per child/family, excluding
visits solely for Peer Support Services. For pre-admission visits at least the
code for unspecified Illness must be entered on the claim.
(c) Medicaid claims may be submitted for no
more than three services, comprising of two psychiatric services and one
health service, per day for any individual, not including crisis intervention,
complex care management, peer support services, or any services that are
provided as part of IOP. For the purposes of this subdivision, psychotropic
medication treatment, injectable psychotropic medication administration,
injectable psychotropic medication administration with monitoring and
education, and complex care management services may be counted as either health
services or psychiatric services. No more than one health physical may be
claimed in one year.
(d) Billing
services.
(1) Assessment services consist of
two types of assessment--Initial Assessment and Psychiatric Assessment. No more
than three initial assessment procedures may be reimbursed by Medicaid.
Additional initial assessment procedures are eligible for Medicaid
reimbursement when more than 365 days have transpired since the most recent
Medicaid reimbursed visit to the Mental Health Outpatient Treatment and
Rehabilitative Service program.
(i) initial
assessment Services shall include performance or consideration, as applicable,
of the Health Screening.
(ii) The
Mental Health Outpatient Treatment and Rehabilitative Service program must
document a minimum of 45 minutes face-to-face contact with the individual or
family or other collaterals. For school-based services, the duration of such
services may be that of the school period, provided the school period is of a
duration of at least 40 minutes.
(iii) Mental Health Outpatient Treatment and
Rehabilitative Service programs may bill the physician modifier when
psychiatrists, nurse practitioners in psychiatry, or physicians approved
pursuant to Section
599.9 of this Part spend at least
15 minutes serving the individual during the time the initial assessment is
being conducted by another licensed practitioner.
(iv) A Psychiatric Assessment may be provided
to either an individual being assessed for admission to the Mental Health
Outpatient Treatment and Rehabilitative Service program, or an individual who
is currently admitted. Psychiatric assessments may be performed for admitted
recipients where medically necessary without limitations. Psychiatric
Assessments may include such elements as a diagnostic interview and treatment
plan development.
(a) A Psychiatric
Assessment may be provided by a physician, psychiatrist, nurse practitioner in
psychiatry, or physician assistant with specialized training approved by the
Office to an individual who has been admitted to the Mental Health Outpatient
Treatment and Rehabilitative Service program, or one for whom the
appropriateness of admission is being assessed.
(b) A Psychiatric Assessment of at least 30
minutes of documented face-to-face interaction between the individual, or
family or other collaterals, and the physician, psychiatrist, or nurse
practitioner in psychiatry, shall be billed as a Brief Psychiatric
Assessment.
(c) A Psychiatric
Assessment of at least 45 minutes of documented face-to-face interaction
between the individual, or family or other collaterals, and the physician,
psychiatrist or nurse practitioner in psychiatry, shall be billed as an
Extended Psychiatric Assessment.
(d) Programs shall comply with the most
recent applicable AMA coding guidelines regarding the appropriate use of
evaluation and management codes for Psychiatric Assessment services, including
minimum duration standards for the provision of psychotherapy services provided
by physicians and nurse practitioners. Where clinically appropriate and
consistent with applicable AMA coding guidelines for service duration ranges
for evaluation and management codes, programs may bill for Brief or Extended
Psychiatric Assessments for shorter service durations than those specified in
this subparagraph.
(2) Psychiatric Consultation.
(i) Psychiatric Consultation may be provided
by a Physician, Psychiatrist, Nurse practitioner, or Psychiatric nurse
practitioner to a referring physician for the purposes of assisting in the
diagnosis, integration of treatment, or assistance in ensuring continuity of
care, for a n individual receiving services from a referring
physician.
(ii) Psychiatric
Consultation services must be face-to-face with the individual, or using
telehealth, where approved by the Office and shall be billed by the Program in
the same manner as Psychiatric Assessments pursuant to paragraph (1) of this
subdivision.
(3) Crisis
Intervention.
(i) The Mental Health
Outpatient Treatment and Rehabilitative Service program may make contractual
arrangements for after-hours crisis coverage by clinicians, but contracts for
this service must be approved by the local governmental unit in which the
Mental Health Outpatient Treatment and Rehabilitative Service program is
located, or by the Office for county-operated Mental Health Outpatient
Treatment and Rehabilitative Service programs.
(ii) Crisis Intervention Services consist of
three billable levels of service.
(a) Crisis
Intervention--Brief. Brief Crisis Intervention Services shall be done in person
or via telehealth. For services of a duration of at least 15 minutes, one unit
of service shall be billed. For each additional service increment of at least
15 minutes, an additional unit of service may be billed, up to a maximum of six
units per day.
(b) Crisis I
ntervention--Complex. Complex Crisis Intervention requires a minimum of one
hour of face-to-face contact by two or more clinicians. Both clinicians must be
present for the majority of the duration of the total contact. Certified Peer
Specialists, Credentialed Family Peer Advocates, and Credentialed Youth Peer
Advocates, or paraprofessional staff may substitute for one clinician. Mental
Health Outpatient Treatment and Rehabilitative Service program may be
reimbursed for crisis intervention-complex services provided to individuals who
have not engaged in services for a period of up to two years.
(c) Crisis I ntervention--Per Diem. Per Diem
Crisis Intervention requires three hours or more of face-to-face contact by two
or more clinicians. Both clinicians must be present for the majority of the
duration of the total contact. Certified Peer Specialists, Credentialed Family
Peer Advocates, and Credentialed Youth Peer Advocates, or paraprofessional
staff may substitute for one clinician. Mental Health Outpatient Treatment and
Rehabilitative Service programs may be reimbursed for crisis intervention-per
diem services provided to individuals who have not engaged in services for a
period of up to two years.
(4) Injectable Psychotropic Medication
Administration services are reimbursed for in person contact between a
clinician and the individual. Injectable Psychotropic Medication Administration
Services consist of two billable levels of service.
(i) Injectable Psychotropic Medication
Administration service has no minimum time limit. This service includes
medication injection.
(ii)
Injectable Psychotropic Medication Administration with Monitoring and Education
requires a minimum of 15 minutes. This service includes medication injection,
monitoring and individual education, as necessary. If the Injectable
Psychotropic Medication Administration with Monitoring and Education Service is
provided to an individual by a Psychiatrist, Physician, Nurse practitioner, or
Psychiatric Nurse Practitioner, it shall not be claimed in addition to an
evaluation and management service (including psychiatric assessment and
psychotropic medication treatment) received by that individual on the same day.
In this case, the Mental Health Outpatient Treatment and Rehabilitative Service
program may claim reimbursement for an Injectable Psychotropic Medication
Administration procedure instead.
(5) Psychotropic Medication Treatment
services are reimbursed for face-to-face contact of at least 15 minutes in
duration between a Psychiatrist, Physician, Nurse practitioner, or Psychiatric
Nurse Practitioner, and the individual.
(6) Psychotherapy services. Psychotherapy
services consist of the following levels of billable service.
(i) Psychotherapy services individual shall
be reimbursed as follows:
(a) A psychotherapy
service provided face to face with the individual with a documented duration of
30 minutes shall be billed as a brief psychotherapy service.
(b) A psychotherapy service provided face to
face with the individual with a documented duration of 45 minutes shall be
billed as an extended psychotherapy service.
(c) Brief and Extended Psychotherapy services
may be billed where more than half of the minimum service duration is spent
providing services to the individual and the remainder of the minimum service
duration is spent providing service to a collateral.
(d) Programs shall comply with applicable AMA
coding guidelines regarding the appropriate use of evaluation and management
codes for Psychotherapy services. Where clinically appropriate and consistent
with applicable AMA coding guidelines for service duration ranges for
evaluation and management psychotherapy codes, programs may bill for Brief or
Extended Psychotherapy for shorter service durations than those specified in
this subparagraph.
(ii)
Psychotherapy Family/Collateral with the individual requires documented
cumulative, continuous face-to-face service with the individual and the
collateral of a minimum duration of 50 minutes, during which time the
individual shall be present for at least the majority of the time.
(iii) Psychotherapy Family/Collateral Without
the individual requires documented face-to-face service with the collateral of
a minimum duration of 30 minutes. For this service, the individual may also be
present for some or all of the time. Where clinically appropriate and
consistent with applicable AMA coding guidelines for service duration ranges
for evaluation and management psychotherapy codes, programs may bill for
Psychotherapy-Family/Collateral Without the Individual for shorter service
durations than those specified in this subparagraph.
(iv) Psychotherapy Multi- Individual Group
requires documented face-to-face service with a minimum of two recipients and a
maximum of 12 recipients for services of a minimum duration of 60 minutes. For
services of a duration of at least 40 minutes and less than 60 minutes,
reimbursement will be reduced by 30 percent.
(v) Psychotherapy Multi-Family/Collateral
Group requires documented face-to-face service with a minimum of two
multifamily/ collateral units and a maximum of eight multifamily/ collateral
units in the group, with a maximum total number in any group not to exceed 16
individuals, and a minimum duration of 60 minutes of service. For services of a
duration of at least 40 minutes and less than 60 minutes, reimbursement will be
reduced by 30 percent.
(7) Testing Services, including Developmental
Testing, Neurobehavioral Status Examination, and Psychological Testing. Medical
Assistance may reimburse for this service solely for individuals admitted to
the Mental Health Outpatient Treatment and Rehabilitative Service program.
Developmental Testing services must be face-to-face with the
individual.
(8) Complex care
management must be provided no later than within 14 calendar days following a
face-to-face psychotherapy, psychotropic medication treatment, or crisis
intervention mental health outpatient program service. A maximum of four units
of at least five consecutive minutes of complex care management may be billed
following each face-to-face psychotherapy, psychotropic medication treatment,
or crisis intervention service. Each full five-minute unit may be provided on
separate days within the 14-calendar day limit, with a maximum of four full
five-minute units associated with each eligible Mental Health Outpatient
Treatment and Rehabilitative Service program visit. The time spent documenting
the provision of complex care management or in other documentation activities
shall not be included in the calculation of time for the purposes of billing of
complex care management.
(9)
Peer/Family Support Services may be provided to individuals, family or other
collaterals, or groups of individuals not to exceed 12. For services of a
duration of at least 15 minutes, one unit of service shall be billed. For each
additional service increment of at least 15 minutes, an additional unit of
service may be billed, up to twelve units per day, or 3 hours maximum. Multiple
units of Peer/Family Support Services may be provided consecutively or at
different times of the day.
(e) Modifiers. Billing modifiers, including
modifiers paid as supplementary rates to visits, are available pursuant to this
section as indicated in the modifier chart included in this subdivision.
Modifier Chart for Services Provided On-Site
|
Office of Mental Health
Service Name |
After
Hours |
Language other than
English |
Physician/
NPP |
|
Complex Care Management |
x |
x |
|
Crisis Intervention
Service -brief |
x |
x |
|
Crisis Intervention Service - Complex
|
x |
x |
|
Crisis Intervention
Service - Per Diem |
x |
x |
|
Peer/Family Support
Services |
x |
x |
|
Developmental, Neurobehavioral Status
Exam, and
Psychological Testing |
x |
x |
|
Injectable Psychotropic Medication
Administration with Monitoring and Education
|
x |
x |
|
Psychotropic Medication Treatment |
x |
|
Initial Mental Health Assessment, Diagnostic
Interview, and Treatment Plan Development |
x |
x |
x |
|
Psychiatric Assessment - brief |
x |
x |
|
Psychiatric Assessment - extended |
x |
x |
|
Individual
Psychotherapy - brief |
x |
x |
x |
|
Individual
Psychotherapy - extended |
x |
x |
x |
|
Group and Multifamily/Collateral
Group Psychotherapy |
x |
x |
x |
|
Family
Therapy/Collateral w/o patient |
x |
x |
x |
|
Family
Therapy/Collateral with patient |
x |
x |
x |
(f)
A Mental Health Outpatient Treatment and Rehabilitative Service program may not
be reimbursed for services provided to an individual currently enrolled in
another program licensed by the Office for which Medicaid reimbursement is
being made except as provided in this subdivision.
(1) Reimbursement shall be made for up to
three pre-admission visits when a n individual is in transition from another
outpatient program, except another Mental Health Outpatient Treatment and
Rehabilitative Service program. After completion of the three preadmission
visits, a Mental Health Outpatient Treatment and Rehabilitative Service program
provider may not bill Medical Assistance for a service unless it is medically
necessary, performed pursuant to a treatment plan approved pursuant to this
Part, and, except as specified in this subdivision, the individual has been
discharged from the other outpatient program.
(2) Reimbursement shall be made for a n
individual currently admitted to a continuing day treatment program in
accordance with Part 587 of this Title when such individual shall also be
admitted to a Mental Health Outpatient Treatment and Rehabilitative Service
program solely for the purpose of clozapine medication therapy. Reimbursement
shall be made for no more than five clozapine medication treatment visits per
month per individual.
(3)
Reimbursement shall be made for services provided, including preadmission
visits, without regard to an individual's enrollment in more than one,
different Mental Health Outpatient Treatment and Rehabilitative Service
programs, except reimbursement shall not be made to more than one program for
the same service on the same date of service.
(4) Reimbursement shall not be made for
services rendered by a Mental Health Outpatient Treatment and Rehabilitative
Service program to residents of a residential health care facility.
Reimbursement shall be made to the Mental Health Outpatient Treatment and
Rehabilitative Service program by the residential health care
facility.
(g) The Office
will only consider requests for revisions of fees calculated under the
provisions of this Part due to errors made by the Office in its calculation.
(1) A request for revision of a fee
calculated in accordance with this section shall be sent to the Commissioner by
registered or certified mail and shall contain a detailed statement of the
basis for the requested revision together with any documentation that the
provider of service wishes to submit.
(2) A request for revision must be submitted
within 120 days of receipt by the provider of service of the rate
computation.
(3) The provider of
service shall be notified in writing of the Commissioner's determination,
including a statement of the reasons therefor.
(h) Miscellaneous billing rules.
(1) Services provided by Mental Health
Outpatient Treatment and Rehabilitative Service programs operated by agencies
licensed under article 28 of the Public Health Law, which are also licensed
pursuant to article 31 of the Mental Hygiene Law, shall not be considered to be
specialized services pursuant to section 2807 of the Public Health
Law.
