Section 1153.52. Payment conditions for various services

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

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

(2) Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview with the patient. 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 clinic medication visit shall be provided only by a psychiatrist, physician, registered nurse or licensed practical nurse who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing.

(7) Within 15 consecutive calendar days following intake, a mental health professional or mental health worker under the supervision of a mental health professional, shall examine and initially assess each patient in the clinic; determine the patient’s diagnosis and prepare an initial treatment plan; and date and sign the examination, diagnosis 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) The psychiatrist shall verify each patient’s diagnosis and approve the treatment plan prior to the provision of any treatment beyond the 15th day following intake. This review and approval shall be dated and signed in the patient’s record.

(ii) The psychiatrist and mental health professional, or mental health worker under the supervision of a mental health professional, shall review and update each patient’s treatment plan at least every 120 days or 15 clinic visits, whichever is first, or, as may otherwise be required by law throughout the duration of treatment. Each review and update shall be dated, documented and signed in the patient’s record by the psychiatrist and mental health professional.

(iii) The treatment plan and updates shall be based upon the evaluation and diagnosis. Treatment shall be provided in accordance with the treatment plan and updates. Psychiatrists’ reviews and reevaluations of diagnoses, treatment plans and updates shall be done with the mental health professional or mental health worker under the supervision of a mental health professional, in the clinic and, whenever possible, with the patient.

(8) The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for a person receiving clozapine therapy.

(b) Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric outpatient partial hospitalization provided to eligible patients with mental disorders in approved psychiatric outpatient partial hospitalization facilities under the following conditions:

(1) Patients receiving partial hospitalization 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) Have a psychiatric condition requiring provision of a supervised, protective setting for a prescribed time period to prevent institutionalization or ease the transition from inpatient care to more independent living.

(2) The following components shall be available in an approved psychiatric partial hospitalization facility and provided to the patient, if necessary, in accordance with the patient’s 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, 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 provided to eligible patients with mental disorders in approved psychiatric outpatient clinics under the following conditions:

(1) Psychiatric clinic medication visits shall be a minimum duration of 15 minutes. They shall be provided only for the purpose of administering medication, and for evaluating the physical and mental condition of the patient during the course of prescribed medication.

(2) Patients receiving psychiatric clinic services shall have a mental disorder diagnosis verified by a psychiatrist.

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

(4) Psychiatric clinic clozapine monitoring and evaluation visits shall be a minimum duration of 15 minutes. They shall be provided only for a person receiving clozaril and for monitoring and evaluating the patient’s white blood cell count to determine whether clozapine therapy should be continued or modified.

(d) Psychiatric clinic services provided in the home. Psychiatric clinic services delivered in the patient’s home are subject to the conditions and limitations established in the chapter. Home visits, as defined in § 1153.2 (relating to definitions), are compensable as outpatient psychiatric services listed in the MA Program Fee Schedule only if the physician’s documentation in the patient’s records and progress notes fully substantiates that one of the following conditions exists:

(1) The client’s disability requires specialized transportation which is not generally available.

(2) The client has a behavior disorder which disrupts the clinic environment.

(3) The client has a diagnosis of agoraphobia.

(e) Observation of the client in the home environment. Observation of the client in the home environment is considered to be an individual psychotherapy service and is compensable only when:

(1) The client is currently in therapy.

(2) Observation of the client in his home setting is a necessary component of the clients’ psychotherapeutic regimen.

The provisions of this § 1153.52 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361. Immediately preceding text appears at serial pages (131009) to (131012).

Notation

Cross References

This section cited in 55 Pa. Code § 1153.2 (relating to definitions); and 55 Pa. Code § 1153.14 (relating to noncovered services).