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

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