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

Current through Register Vol. 54, No. 28, July 13, 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.