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Introduction
This document provides a summary of the requirements included in the NYS Office of Mental Health's outpatient regulations, as they pertain to receipt of Medicaid payments. These requirements have been extracted from 14 NYCRR Parts 587 and 588, which are applicable to clinic treatment programs, continuing day treatment programs, day treatment programs for children, intensive psychiatric rehabilitation treatment programs, and partial hospitalization programs. In some instances, additional guidance or clarification is provided. The document is organized into the following three sections:
The Eligibility section outlines the minimum requirements which must be met in order for a specific provider to be able to bill Medicaid on behalf of a specific individual, for a given service. The Billing section summarizes the basic billing rules and limitations. The Documentation section summarizes the requirements which, when met, provide supporting documentation that the eligibility and billing requirements have been met. Even when there is not a specific documentation requirement included in the regulations, providers are advised to ensure that they have sufficient documentation to verify compliance with other standards. There is no practice or approach that substitutes for thorough, accurate and timely record keeping.
Providers are advised that this document is not a substitute for a careful review of the applicable regulations. In the event of any conflict between this document and 14 NYCRR Parts 587 and 588, the regulations are controlling.
Providers are encouraged to maintain up-to-date copies of the regulations, and to ensure that they are accessible to relevant staff. The regulations are available on OMH's website at www.omh.state.ny.us/omhweb/policy_and_regulations/.
Eligibility for Reimbursement
Program | Admission Criteria |
---|---|
Clinic Treatment Program | designated mental illness diagnosis |
Continuing Day Treatment Program | designated mental illness diagnosis and dysfunction due to mental illness |
Day Treatment Program for Children | designated mental illness diagnosis, plus either an extended impairment in functioning due to emotional disturbance or a current impairment in functioning with severe symptoms |
Intensive Psychiatric Rehabilitation Treatment Program | designated mental illness diagnosis, dysfunction due to mental illness which is likely to continue for a prolonged time, readiness to participate in the program, and referral by a licensed practitioner |
Partial Hospitalization Program | designated mental illness diagnosis which has resulted in dysfunction due to acute symptomatology which requires medically supervised intervention to achieve stabilization and which, but for the availability of a partial hospitalization program, would necessitate admission to, or continued stay in, an inpatient hospital |
Designated mental illness diagnosis is a DSM diagnosis (or ICD equivalent) other than: 1) alcohol or drug disorders; 2) developmental disabilities; 3) organic brain syndromes; 4) social conditions (V-Codes). V-Code 61-20 Parent-Child problem is included for eligibility for services in clinic treatment programs serving children with a diagnosis of emotional disturbance. |
Note: While program activities can be described in multiple ways and many providers prefer to use local terminology, providers are advised, whenever practicable, to use the service labels included in the regulations to ensure that the meaning and intent of the service is understood by external reviewers. As an alternative, providers are advised to develop a "crosswalk", comparing provider terminology with regulatory language. |
Note: While the person rendering the service may include a member of the professional staff, a non-professional member of the clinical staff, or an identified volunteer, such person should be reflected on the provider's staffing plan. |
Clinical support services are services provided to collaterals, by at least one therapist, with or without recipients for the purpose of providing resources and consultation for goal oriented problem solving, assessment of treatment strategies and provision of skill development to assist the recipient in management of his or her illness. |
Collateral persons are members of the recipient's family or household, or significant others who regularly interact with the recipient and are directly affected by or have the capability of affecting his or her condition and are identified in the treatment or psychiatric rehabilitation service plan as having a role in treatment and/or identified in the pre-admission notes as being necessary for participation in the evaluation and assessment of the recipient prior to admission. A group composed of collaterals of more than one recipient may be gathered together for purposes of goal-oriented problem solving, assessment of treatment strategies and provision of practical skills for assisting the recipient in the management of his or her illness. |
Note: An individual cannot be considered a "collateral person" based on his or her role as a staff member of the outpatient program, or any other mental health service provider. |
Program | Visit Category & Duration |
---|---|
Clinic Treatment Program | Pre-admission: 30+ minutes Brief: 15 - 29 minutes Regular: 30+ minutes Crisis: 30+ minutes Group: 60+ minutes Collateral: 30+ minutes Group collateral: 1 - 2 hours |
Continuing Day Treatment Program | Pre-admission: 1 hour+ 1 - 5 hours (recipient visit) Collateral: 30 minutes - 2 hours Group collateral: 1 - 2 hours |
Day Treatment Program for Children | Pre-admission: 3 hours+ Full: 5+ hours Half: 3 - 5 hours Brief: 1 - 3 hours Collateral: 30+ minutes Home: 30+ minutes Crisis: 30+ minutes |
Intensive Psychiatric Rehabilitation Treatment Program | Pre-admission: 1 hour+ 1 - 5 hours |
Partial Hospitalization Program | Pre-admission: 1 hour+ 4 - 7 hours (recipient visit) Collateral: 30 minutes - 2 hours Group collateral: 1 - 2 hours |
Most Common Reasons for Medicaid Disallowances Associated with Eligibility |
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Billing Requirements and Limitations
Note: The mental illness diagnosis is not required to be the primary diagnosis. For pre-admission visits, "diagnosis deferred" (799.9) may be used. |
* Note: A single visit can include multiple services, provided by multiple members of the clinical staff. Multiple, non-contiguous contacts during a single day may be aggregated for a single bill. |
Note: Although co-enrollment is permitted in the above circumstances, visits to multiple programs cannot occur on the same day. |
Program | Rate Codes |
---|---|
Clinic Treatment Program | 4301 - 4306 |
COPs-Only* | 4093 - 4098 |
Interim Specialty Clinics* | 4601 - 4606 |
Continuing Day Treatment Program | 4307 - 4348 |
Day Treatment Program for Children | 4060 - 4067 |
Intensive Psychiatric Rehabilitation Treatment Program | 4364 - 4368 |
Partial Hospitalization Program | 4349 - 4363 |
* For use on behalf of persons enrolled in Medicaid Managed Care. (Interim Specialty Clinics are also commonly referred to as "SED Clinics.")
Most Common Reasons for Medicaid Disallowances Associated with Billing |
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Supporting Documentation
Note: The dates of service in this record must match the dates of service reflected in the Medicaid claim. |
Note: Although some providers include this information in the progress notes, a separate service record may be maintained. Regardless of the approach used, providers should consider adopting a consistent approach by all clinicians throughout the program. Such consistency would aid the process of any external review. |
Program | Completion of Treatment/Service Plan |
---|---|
Clinic Treatment Program | prior to the fourth visit after admission, or within 30 days of admission, whichever comes first |
Continuing Day Treatment Program | prior to the twelfth visit after admission, or within 30 days of admission, whichever comes first |
Day Treatment Program | for Children within 30 days of admission |
Intensive Psychiatric Rehabilitation Treatment Program | within five visits after admission |
Partial Hospitalization Program | prior to the fourth visit after admission |
Program | Treatment/Service Plan Reviews |
---|---|
Clinic Treatment Program | every three months |
Continuing Day Treatment Program | every three months |
Day Treatment Program for Children | every three months |
Intensive Psychiatric Rehabilitation Treatment Program | every month |
Partial Hospitalization Program | every two weeks |
Program | Completion of Progress Notes |
---|---|
Clinic Treatment Program | every visit |
Continuing Day Treatment Program | every two weeks |
Day Treatment Program for Children | every week |
Intensive Psychiatric Rehabilitation Treatment Program | N/A (part of monthly service plan review) |
Partial Hospitalization Program | every visit |
Note: Treatment/service plans and related reviews, and progress notes, when signed, should be dated so that compliance with completion schedules can be tracked. |
Program | Utilization Review Schedule |
---|---|
Clinic Treatment Program | within 30 days of admission, and every 6 months thereafter |
Continuing Day Treatment Program | by the 12th visit, or within 30 days of admission, and every 6 months thereafter |
Day Treatment Program for Children | within 30 days of admission, and every 6 months thereafter |
Intensive Psychiatric Rehabilitation Treatment Program | within 30 days of admission, and every 3 months thereafter |
Partial Hospitalization Program | by 4th visit after admission, and every 2 weeks thereafter |
Most Common Reasons for Medicaid Disallowances Associated with Documentation |
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