Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES
PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES
Section 1153.52 - Payment conditions for various services

Universal Citation: 55 PA Code ยง 1153.52

Current through Register Vol. 54, No. 44, November 2, 2024

(a) The following conditions shall be met by psychiatric outpatient clinics and partial hospitalization outpatient programs, as applicable, to be eligible for payment:

(1) A psychiatrist shall be present in the psychiatric outpatient clinic and partial hospitalization outpatient facility, as required by the Office of Mental Health and Substance Abuse Services licensing regulations, to perform or supervise the performance of all covered services provided to MA beneficiaries.

(2) Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview or using interactive audio and video communication that conforms to industry-wide technology standards with the individual and is in compliance with State and Federal privacy and security laws. Additional interviews with other staff may be included as part of the examination but shall be included in the psychiatric evaluation fee. Separate billings for these additional interviews are not compensable.

(3) Psychotherapy-individual, family, collateral family or group-shall be provided only by a clinical staff person.

(4) Psychiatric partial hospitalization services shall be provided only by a clinical staff person.

(5) Diagnostic psychological and intellectual evaluations shall be administered and interpreted only by a licensed psychologist or by a psychologist in preparation for licensure under the direct supervision of a licensed psychologist.

(6) The psychiatric outpatient clinic medication visit shall be provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.

(7) Within 30 consecutive calendar days following intake for individuals who continue to participate in the treatment process, a mental health professional or mental health worker under the supervision of a mental health professional, shall:
(i) Interview and complete an assessment with each individual receiving services from the psychiatric outpatient clinic.

(ii) Develop the initial treatment plan based upon the assessment in collaboration with the individual.

(iii) Date and sign the initial treatment plan.

(iv) Request the individual to sign and date the treatment plan. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.

(8) The initial treatment plan shall be reviewed and approved in accordance with the following:
(i) If the individual is receiving psychotherapy and other clinic services, the psychiatrist or advanced practice professional shall review, approve, sign and date the initial treatment plan.

(ii) If the individual is receiving medication management services only, the psychiatrist, physician, certified registered nurse practitioner or physician assistant responsible for prescribing and monitoring the use of the medications shall sign and date the initial treatment plan.

(iii) The initial treatment plan shall be developed, reviewed, approved, dated and signed prior to the provision of any treatment services beyond the 30th day following intake.

(iv) The initial treatment plan shall be kept in the individual record.

(9) The treatment plan shall be reviewed and updated at least every 180 days or as may otherwise be required by law throughout the duration of treatment in accordance with the following:
(i) The treatment plan updates shall be based upon the assessment, diagnosis and input from the treatment team and individual receiving services.

(ii) The treatment plan update shall be signed and dated by the mental health professional, mental health worker under the supervision of the mental health professional, certified registered nurse practitioner or physician assistant providing treatment services to the individual.

(iii) The mental health professional or the mental health worker shall request the individual to sign and date the treatment plan update. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.

(iv) The treatment plan update shall be kept in the individual record.

(10) Treatment shall be provided in accordance with the identified goals in the treatment plan and updates.

(11) The treatment plan shall be reviewed on an annual basis by the psychiatrist or advanced practice professional throughout the course of treatment from the psychiatric outpatient clinic and the review documented in the individual record.

(12) The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for an individual receiving clozapine therapy.

(b) Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric partial hospitalization outpatient services provided to eligible individuals with mental illness or emotional disturbance in psychiatric partial hospitalization outpatient facilities under the following conditions:

(1) Individuals receiving partial hospitalization outpatient services shall meet the following criteria:
(i) Have a mental disorder diagnosis that has been verified by a psychiatrist.

(ii) Have a psychiatric condition requiring more intensive treatment than that provided by an outpatient clinic.

(iii) Be diagnosed with a mental illness or emotional disturbance and prescribed services for a period of at least 3 hours but less than 24 hours in any 1 day to prevent hospitalization or to support the transition from inpatient treatment to outpatient services.

(2) The following components shall be available in a psychiatric partial hospitalization outpatient facility and provided to an individual, if necessary, in accordance with the individualized treatment plan:
(i) Individual, group and family psychotherapy.

(ii) Health education-basic physical and mental health information; nutrition information and assistance in purchasing and preparing food, personal hygiene instruction; basic health care information, child care information and family planning information and referral; information on prescribed medications.

(iii) Instruction in basic care of the home or residence for daily living.

(iv) Instruction in basic personal financial management for daily living.

(v) Medication administration and evaluation provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.

(vi) Guided social interaction supervised by psychiatric partial hospitalization personnel.

(vii) Crisis management provided by psychiatric partial hospitalization personnel.

(viii) Referral.

(c) Psychiatric outpatient clinic. Payment will only be made for psychiatric outpatient clinic services or MMHT services provided to eligible individuals with mental illness or emotional disturbance by psychiatric outpatient clinics under the following conditions:

(1) Medication visits shall be provided only for the purpose of administering medication and for evaluating the physical and mental condition of an individual during the course of prescribed medication.

(2) Individuals receiving psychiatric outpatient clinic services or MMHT services shall have a mental illness or emotional disturbance diagnosis verified by a psychiatrist or LPHA.

(3) Family psychotherapy is compensable only if one or more family members has a mental disorder diagnosis.

(4) Clozapine monitoring and evaluation visits shall be provided only for an individual receiving clozapine and for monitoring and evaluating the individual's absolute neutrophil count to determine whether clozapine therapy should be continued or modified.

(d) MMHT. MMHT services are subject to the conditions and limitations established in this chapter. MMHT services provided in the home or other approved community sites are compensable only if documentation in the individual record substantiates all of the following:

(1) The services are provided to an eligible individual with mental illness or emotional disturbance.

(2) There is a written recommendation for MMHT services from a LPHA acting within the scope of professional practice.

(3) The services if provided in a psychiatric outpatient clinic would be medically necessary.

(4) The assessment documents a mental or physical illness that impedes or precludes the individual's ability to participate in services at the psychiatric outpatient clinic.

(5) Treatment plan updates document the continued clinical need for MMHT services.

The provisions of this §1153.52 amended under section 201(2) of the Human Services Code (62 P.S. § 201(2)).

This section cited in 55 Pa. Code § 1153.14 (relating to noncovered services).

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