Note: All requirements in 471 NAC 20-001 apply to outpatient psychiatric services.
002.01Covered Outpatient Psychiatric Therapeutic Services Nebraska Medical Assistance Program covers the following outpatient psychiatric therapeutic services for clients age 21 and older as defined in 471 NAC 20-001.12:
1. Psychiatric evaluation;2. Psychological evaluation;3. Psychological testing;4. Individual Psychotherapy;5. Group Psychotherapy (a group overview must be approved by Medicaid prior to billing for this service);6. Family Psychotherapy Services;8. Medication checks by a physician or a physician extender;9. Electroconvulsive Therapy. Treatment for chemical dependency is not covered for clients age 21 and older.
Skilled nursing services for the monitoring of medications is available through Home Health Agencies (see 471 NAC 9-000).
002.02Psychiatric Therapeutic Staff Standards The following psychiatric therapeutic staff may provide services and must meet the requirements as defined in 471 NAC 20-001.13 -
2. Licensed Psychologist;4. Licensed Independent Mental Health Practitioner;5. Allied Health Therapists.20-002.02ALocation of Services: Outpatient psychiatric services by qualified staff may be provided in - 1. A licensed community mental health program which meets the criteria for approval by the Joint Commission on Accreditation of Healthcare Organizations, CARF, COA, or AOA;2. A licensed and certified hospital which provides psychiatric services and which - a. Is maintained for the care and treatment of patients with primary psychiatric disorders;b. Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard -setting in that state;c. Is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or AOA;d. Has licensed and certified psychiatric beds;e. Meets the requirements for participation in Medicare for psychiatric hospitals; andf. Has in effect a utilization review plan applicable to all Medicaid clients;3. A licensed and certified hospital which provides acute medical services and which - a. Is maintained for the care and treatment of patients with acute medical disorders;b. Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard -setting in that state;c. Is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or AOA;d. Meets the requirements for participation in Medicare for acute medical hospitals; ande. Has in effect a utilization review plan applicable to all Medicaid clients;4. A physician's private office;5. A licensed psychologist's private office;6. An allied health therapist's private office;9. Rural Mental Health Clinics or Federally Qualified Health Centers.Therapy is not reimbursable in any other location.
002.03Provider Agreement A provider of psychiatric outpatient services shall complete a provider agreement, and submit the form to the Department for approval:
1. Independent psychiatric service providers (physicians, licensed psychologists) shall complete Form MC-19, "Medical Assistance Provider Agreement." The provider agreement issued to the supervising practitioner (or clinic) is used to claim services provided by allied health therapists who are in his/her employ or supervision. For outpatient psychiatric services provided through a group practice, the Provider Agreement must be kept current by providing the Department with: a. The termination date of any therapist leaving the group practice;b. The initial employment date of any therapist joining the group practice;c. A current resume detailing education and clinical experience for each application for allied health therapists.2. Hospitals as defined in 471 NAC 20-002.02A providing outpatient psychiatric services shall complete Form MC-20, "Medical Assistance Hospital Provider Agreement." Providers are responsible for verifying that allied health therapists, physicians, physician extenders, and licensed psychologists are appropriately licensed for the correct scope of practice.
20-002.03AGeographically-Deprived Areas: A geographically-deprived area is an area where a psychiatrist is not available in the community, or within a reasonable driving distance of the community, to provide services. A physician who is qualified, skilled, and experienced in the diagnosis and treatment of psychiatric disorders may serve as an alternative to a psychiatrist for outpatient services in a geographically-deprived area. A resume detailing the physician's mental health education and experience must accompany the provider agreement. When outpatient psychiatric services are provided under these conditions, the physician is subject to all policy requirements outlined for psychiatrists. Psychiatric services provided by the attending physician, other than a psychiatrist, are limited to the following: Psychotherapy services provided in a physician's office which do not exceed six months without documented consultation between the physician providing the service and a psychiatrist.
002.04Coverage Criteria for Outpatient Psychiatric Services The Nebraska Medical Assistance Program covers outpatient psychiatric therapeutic services listed in 471 NAC 20002.01 when the services are medically necessary and provide active treatment as defined in 471 NAC 20-001.15 and 20-001.16.
Medical necessity and active treatment for outpatient services is documented through the use of the Department's approved treatment planning document (471 NAC 20-002.06) which must be developed by a licensed practitioner and supervising practitioner based on a thorough evaluation of the client's restorative needs and potentialities for a primary psychiatric diagnosis.
20-002.04AServices Provided by Allied Health Therapists: Services provided by Allied Health Therapists (as defined in 471 NAC 20-001.13) must be prescribed and provided under the direction of a supervising practitioner. Supervision must meet the active treatment criteria in 471 NAC 20-001.16. Definition and Practice of Supervision: Supervision by the supervising practitioner is defined as the critical oversight of a treatment activity or course of action. This includes, but is not limited to, review of treatment plan and progress notes, client specific case discussion, periodic assessments of the client (annually, or more often if necessary), and diagnosis, treatment intervention or issue specific discussion. The supervising practitioner is a source of information and guidance for all members of the treatment team and their participation in services as an essential ingredient for all members of the treatment. The critical involvement of the supervising practitioner must be reflected in the Initial Diagnostic Interview, the treatment plan, and the interventions provided.
The supervising practitioner (or their designated and qualified substitute) must be available, in person or by telephone, to provide assistance and direction as needed during the time the services are being provided.
Supervisory contact may occur in a group setting.
Supervision is not billable by either the therapist or the supervising practitioner as it is considered a mandatory component of the care.
Psychiatric resident physicians and physician extenders may not supervise allied health therapists for Medicaid services.
The supervising practitioner shall periodically evaluate the therapeutic program and determine if treatment goals are being met and if changes in direction or emphasis are needed.
The supervising practitioner must personally re-evaluate the client through a face-to-face contact annually or more often, if necessary.
002.05Initial Diagnostic Interview Before a client is accepted for treatment, an Initial Diagnostic Interview must be completed.
The supervising practitioner must evaluate the client within four weeks of the initial contact with the therapist, or sooner if necessary. If the client does not continue with therapy sessions past the fourth session or does not attend the assessment session with the supervising practitioner, the therapist must review the specific case with the supervising practitioner, to establish a diagnosis and confirm that the interventions were appropriate. For clients continuing in therapy, reimbursement will not be available for more than four sessions until the client is assessed by the supervising practitioner.
002.06Treatment Planning When treatment is initiated, the provider shall work with the client and family (at the client's discretion) to develop the treatment plan. If the client is accepted for treatment, the treatment plan must be completed within two sessions of the assessment by the supervising practitioner and is based on the following:
1. The client must have sufficient need for active psychiatric treatment at the time the psychiatric service provider accepts the client; and2. The treatment must be the best choice for expecting reasonable improvement in the client's psychiatric condition. The goals and objectives documented on the treatment plan must reflect the recommendations from the Initial Diagnostic Interview, the supervising practitioner and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the client's response to the treatment interventions based on the recommendations, goals and objectives.
The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends.
Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings.
Providers must encourage family members to be involved in the assessment of the client, the development of the treatment plan, and all aspects of the client's treatment unless prohibited by the client, through legal action, or because of federal confidentiality laws.
20-002.06ATreatment Planning Document Update: The treatment plan must be reviewed and updated every 90 days, or more frequently if indicated. The client's clinical record must include the supervising practitioner's comments on the client's response to treatment and changes in the treatment plan. The supervising practitioner must review and sign off on the updated treatment plan prior to its initiation. Changes in the treatment plan must be noted on the current treatment planning document. In addition, the psychiatric service provider shall complete an updated treatment planning document annually, or more frequently if necessary, to reflect changes in treatment needs. A copy of the current treatment planning document must be maintained in the client's medical record. For services provided under the supervision of a supervising practitioner, the signature of the supervising practitioner on the treatment planning document indicates his/her agreement that the scheduled treatment interventions are appropriate.
002.07Documentation in Client's Clinical Records All documents submitted to Medicaid must contain sufficient information for identification (i.e., client's name, dates, and time of service, provider's name). Documentation must be legible. The client's medical record must also include -
1. The Initial Diagnostic Interview;2. The treatment plan, (including the initial document, updates, and current);3. The client's diagnosis. A provisional or interim psychiatric diagnosis must be established by the supervising practitioner at the time the client is accepted for treatment. This diagnosis must be reviewed and revised as a part of the treatment plan;4. A chronological record of all psychiatric services provided to the client, the date performed, the duration of the session, and the staff member who conducted the session;5. A chronological account of all medications prescribed, the name, dosage, and frequency to be administered and client's response;6. A comprehensive family assessment;7. A clear record of family and community involvement;8. Documentation verifying coordination with other therapists when more than one provider is involved with the client/family; and9. Transition/discharge planning.002.08Transition/Discharge Planning Services Providers of outpatient psychiatric services shall meet the transition/discharge planning requirements noted in 471 NAC 20-001.18.
002.09Utilization ReviewPayment for outpatient psychiatric services is based on adequate legible documentation of medical necessity and active treatment. All outpatient claims are subject to utilization review before payment. Illegible documentation may result in denial of payment (see 471 NAC 20-001.19).
Additional documentation from the client's clinical record may be requested prior to considering authorization of payment when the treatment plan does not adequately document medical necessity or active treatment.
002.10Guidelines for Specific Services20-002.10APsychological Testing and Evaluation Services: Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual client. Medical necessity must be documented. Testing and evaluation services may be performed by a licensed psychologist, or by a specially licensed psychologist or a master's level person approved to administer psychological testing under the supervision of a licensed psychologist.
If testing and evaluation services are provided by a licensed, non-certified psychologist, the services must be ordered by a supervising practitioner. The treatment plan must be signed by the supervising practitioner.
A copy of the testing narrative summary must be kept in the client's clinical record. If the evaluation is court ordered, the provider shall note this on the treatment plan and include documentation of medical need for the service. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.
20-002.10BGrandparented Masters Psychologists: Services provided by master's level clinical psychologists whose certification has been grandparented by the Department of Health and Human Services, Division of Public Health may be covered under 471 NAC 20002 ff. Documentation of the grandparented status may be required.20-002.10CMedication Checks: Medication checks may only be done when medically necessary. When a physician provides psychotherapy services, medication checks are considered a part of the psychotherapy service. The supervising physician may provide a medication check when a licensed psychologist or an allied health therapist provides the psychotherapy service. Only physicians and psychiatrically trained physician extenders may provide medication checks.
20-002.10DAfter-Care: After-care as defined by the American Psychiatric Association is a complex system of services including, but not limited to, psychotherapy, medication checks, and social, rehabilitative, and educational services required and necessary to deinstitutionalize the chronic patient who has undergone extended hospital treatment and care. This "service package" does not meet the criteria of active treatment and is not covered by the Nebraska Medical Assistance Program. Individually-identified services may be claimed under the appropriate HCPCS/CPT procedure code and are subject to the active treatment standard.20-002.10EProfessional and Technical Components for Hospital Diagnostic and Therapeutic Services: For regulations regarding professional and technical components for diagnostic and therapeutic hospital services, the elimination of combined billing, and non-physician services and items provided to hospital patients, refer to 471 NAC 10-003.05C, 10-003.05D, 10-003.05E, and 10-003.05F.20-002.10FTravel to the Home of Individuals Who Have Handicaps: If a client has a handicapping physical condition that prevents them from traveling to a mental health clinic or office, the provider may request prior authorization to bill for mileage to the client's home. The following requirements must be met: 1. The provider requests prior authorization before the initiation of services;2. The treatment must meet the criteria for active treatment and medical necessity;3. The client's handicapping physical condition prevents their travel to the mental health clinic or office; and4. The client's home is more than 30 miles from the clinic or office. This information must be provided, in writing, to the Medicaid Central Office staff or their designee for consideration.
20-002.10GFamily Assessment: NMAP covers family assessments used to identify the functional level of the family unit and the system changes that would influence this functional level. This includes interviews with the client and collateral parties.002.11Payment for Outpatient Psychiatric Services20-002.11APayment for Outpatient Psychiatric Services in a Hospital: Payment for outpatient psychiatric services is made according to Nebraska Medicaid Practitioner Fee Schedule. The Nebraska Medical Assistance Program (NMAP) pays for covered outpatient mental health services, except for laboratory services, at the lower of - 1. The provider's submitted charge; or2. The allowable amount for that procedure code in the Medicaid Practitioner Fee Schedule for that date of service. The allowable amount is indicated in the fee schedule as - a. The unit value multiplied by the conversion factor;b. The maximum allowable dollar amount; orc. The reasonable charge for the procedure as determined by the Division of Medicaid and Long-Term Care (indicated as "BR" - by report or "RNE" -rate not established in the fee schedule).20-002.11BRevisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to - 1. Comply with changes in state or federal requirements;2. Comply with changes in national standard code sets such as HCPCS and CPT;3. Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and4. Adjust the allowable amount when the Division of Medicaid and Long-Term Care determines that the current allowable amount is - a. Not appropriate for the service provided; orb. Based on errors in data or calculation. The Department may issue revisions of the Nebraska Medicaid Practitioner Fee Schedule during the year that it is effective. Providers will be notified of the revisions and their effective dates.
002.12Billing Requirements For outpatient psychiatric service providers, the following requirements must be met.
1. Community mental health programs providing outpatient psychiatric services shall submit all claims for outpatient services on an appropriately completed Form CMS-1500 (see 471-000-64) or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment for approved outpatient psychiatric services provided by employees of a community mental health program is made to the facility.
2. Hospitals providing outpatient psychiatric services shall submit all claims for non-physician services on an appropriately completed Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). All M.D. services shall be submitted on an appropriately completed CMS-1500.
Payment for approved outpatient psychiatric services provided by employees of a hospital is made to the facility.
3. Independent providers of outpatient psychiatric services (psychiatrist or clinical psychologist in a private office who is not an employee of a hospital or community mental health center) shall submit all claims for outpatient psychiatric services provided in their private office on an appropriately completed Form CMS-1500 (see 471-000-64) or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment for approved outpatient psychiatric services provided in an independent provider's private office is made to the provider as identified on the provider agreement.
20-002.12ADocumentation for Claims: For outpatient psychiatric services, unless otherwise instructed by Medicaid or their designee, the following documentation must be kept in the client's file for each claim:1. The initial treatment plan; or2. An updated version of the treatment plan completed every 90 days.For psychological testing and evaluation services, unless otherwise instructed by Medicaid, the following information must be kept in the client's file:
2. Medical necessity for the service documented on the treatment plan;3. The documentation that the evaluation services will reasonably be expected to contribute to the diagnosis and plan of care established for the individual client; and4. A narrative of the testing results.002.13Procedure Codes and Descriptions HCPCS/CPT procedure codes used by NMAP are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-532).
471 Neb. Admin. Code, ch. 20, § 002