Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES
PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES
Section 1223.52 - Payment conditions for various services
Universal Citation: 55 PA Code ยง 1223.52
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Elibilty for payment. The following conditions shall be met by an outpatient drug and alcohol clinic, as applicable, to be eligible for payment:
(1)
Drug/alcohol clinic visits-methadone maintenance clinic visits, chemotherapy
clinic visits and opiate detoxification clinic visits-shall be provided only by
a licensed physician or other drug/alcohol clinic medical personnel under the
supervision of a physician. Drug-free clinic visits shall be provided by a
licensed physician or by drug/alcohol clinic personnel under the supervision of
a physician.
(2) A comprehensive
medical examination shall be provided only by a licensed physician. Additional
interviews with other staff may be included as part of the comprehensive
medical examination, but shall be included in the comprehensive medical
examination fee. Separate billings for these interviews are not
compensable.
(3) A psychiatric
evaluation shall be provided only by a licensed psychiatrist. Additional
interviews with other staff may be included as part of the psychiatric
evaluation, but shall be included in the psychiatric evaluation fee. Separate
billings for these interviews are not compensable.
(4) Psychotherapy-individual, family or
group-shall be provided only by licensed physicians or other drug/alcohol
outpatient clinic psychotherapy personnel under the supervision of a
physician.
(5) Diagnostic
psychological services-the psychological and intellectual evaluations listed in
the Medical Assistance Program Fee Schedule-shall be provided only by licensed
psychologists under the supervision of a physician.
(6) With the exception of methadone
maintenance clinic services, a DAAP shall perform a level of care assessment
for each patient prior to admission to the clinic and the provision of
services.
(i) Within 15 days following intake,
the clinic's supervisory physician shall review and verify each patient's level
of care assessment, psychosocial evaluation and initial treatment plan prior to
the provision of any treatment beyond the 15th day following intake. The
clinic's supervisory physician shall verify the patient's diagnosis. The
clinic's supervisory physician shall sign and date the patient's level of care
assessment, psychosocial evaluation, treatment plan and diagnosis in the
patient's record. Payment will not be made for services provided within or
beyond the 15th day following intake, without the clinic's supervisory
physician's review and approval of the level of care assessment, psychosocial
evaluation, treatment plan and determination of the patient's diagnosis.
(ii) Sixty days following the date
of the initial treatment plan and at the end of every 60-day period during the
duration of treatment, the clinic's supervisory physician shall review and
update each patient's treatment plan. Each review and update shall be dated,
documented and signed in the patient's record by the clinic's supervisory
physician.
(iii) The treatment plan
and updates shall be based upon the psychosocial evaluation and diagnoses.
Treatment shall be provided in accordance with the treatment plan and updates
and under the supervision and direction of the clinic's supervisory physician.
Clinic supervisory physician reviews and reevaluations of diagnoses, treatment
plans and updates shall be done in the clinic.
(iv) A physician may perform a comprehensive
medical examination or psychiatric evaluation, when medically necessary, as
indicated by either the level of care assessment or the clinic's supervisory
physician's review.
(7)
For methadone maintenance clinics, following intake and prior to the provision
of any services, the clinic's supervisory physician shall perform a
comprehensive medical examination on each patient to determine the patient's
diagnoses, initial treatment plan and identify any medical conditions. The
clinic's supervisory physician shall document and sign the comprehensive
medical examination and treatment plan in the patient's record. The treatment
plan shall be developed, maintained and periodically reviewed in accordance
with the following criteria:
(i) Sixty days
following the date of the initial treatment plan and at the end of every 60-day
period during the duration of treatment, the clinic's supervisory physician
shall review and update each patient's treatment plan. Each review and update
shall be dated, documented and signed in the patient's record by the clinic's
supervisory physician.
(ii) The
treatment plan and updates shall be based upon the comprehensive medical
examination, psychosocial evaluation and diagnoses. Treatment shall be provided
in accordance with the treatment plan and updates and under the supervision and
direction of the clinic's supervisory physician. Clinic supervisory physician
reviews and reevaluations of diagnoses, treatment plans and updates shall be
done in the clinic.
(b) Methadone maintenance clinic visit, chemotherapy clinic visit, drug-free clinic visit and opiate detoxification clinic visit. Payment will only be made for drug/alcohol clinic visits provided to eligible drug/alcohol patients in approved drug/alcohol outpatient clinics under the following conditions:
(1) The visit shall be a minimum duration of
15 minutes.
(2) A drug or
biological furnished to a clinic patient for therapeutic purposes during a
clinic visit, diagnostic laboratory services used to detect the patient's use
of drugs, and supplies provided to the outpatient are included in the clinic
visit fee. This paragraph does not apply to documented, medically necessary
tests for pregnancy and medical conditions such as hepatitis, anemia and
AIDS.
(3) The chemotherapy clinic
visit is only for the purpose of administering medication, such as antabuse or
tranquilizers, and for evaluating the physical and mental condition of the
patient during the course of prescribed medication.
(4) The drug-free clinic visit is only for
the purpose of evaluating a patient's physical and mental condition during a
course of treatment when prescribed medication such as antabuse, methadone or
tranquilizers is not provided to assist in withdrawal or in maintenance.
(c) Psychotherapy. A patient receiving psychotherapy shall be diagnosed by a physician as having a drug/alcohol abuse or dependence problem, in accordance with the International Classification of Diseases, 9th Revision (ICD-9-CM). In the case of family psychotherapy, psychotherapy shall include at least one family member with a drug/alcohol abuse or dependence problem, that is, the clinic patient. Interviews or consultations with family members alone, without the presence of the family member with a drug/alcohol abuse or dependence problem, are considered to be part of the family psychotherapy fee. Separate billings for these interviews are not compensable.
(d) Home visits. The following conditions apply to payment for home visits:
(1) Payment will be made for compensable
drug/alcohol clinic services provided to eligible recipients only under the
following conditions:
(i) The physician
certifies in his handwriting on the invoice submitted for payment that the
patient is severely physically disabled, the nature of the disability and the
reason why the patient could not be transported to the clinic.
(ii) The home visit is made to the patient's
private residence, foster home or home of friend or relative wherein the
patient resides. A home visit is not compensable when made to an inpatient
nonhospital facility, hospital, shelter, partial hospitalization facility,
correctional facility or other location not specifically allowed in this
subsection.
(2) Clinic
services delivered in the home are subject to the conditions and limitations
established in this chapter for clinic services delivered in the clinic
facility.
(3) Group psychotherapy
is not covered.
The provisions of this §1223.52 amended under sections 403(a) and (b), 443.3(1) and 509 of the Public Welfare Code (62 P. S. §§ 403(a) and (b), 443.3(1) and 509).
This section cited in 55 Pa. Code § 1223.14 (relating to noncovered services).
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