Psychiatric day treatment is a service in a continuum of care designed to prevent hospitalization or to facilitate the movement of the acute psychiatric client to a status in which the client is capable of functioning within the community with less frequent contact with the psychiatric health care provider.
Day treatment services must meet all requirements in 471 NAC 20-001.
003.01Covered Day Treatment Services Psychiatric day treatment programs shall provide the following mandatory services and at least two of the following optional services. Payment for both mandatory services and optional services is included in the rate for day treatment. Providers shall not make any additional charges to the Department or to the client.
20-003.01AMandatory Services: The following services must be included in a program for psychiatric day treatment to be approved for participation in the Nebraska Medical Assistance Program. See 471 NAC 20-001 for definitions. 1.Medically Necessary Psychotherapy Services: These services must demonstrate active treatment of a patient with a psychiatric condition. These services are subject to program limitations and must be provided by professionals operating within the appropriate scope of practice. a. Individual Psychotherapy;d. Family Assessment if appropriate;2.Medically Necessary Nursing Services: Services directed by a Registered Nurse who evaluates the particular medical nursing needs of each client and provides for the care and treatment that is indicated by the Department approved treatment planning document approved by the supervising practitioner.3.Medically Necessary Psychological Diagnostic Services: Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual client. Testing and evaluation services may be performed by a Licensed Psychologist. If testing and evaluation services are provided by a specially licensed psychologist or approved Master's level person, the services must be ordered by a supervising practitioner. Medical necessity must be documented by the supervising practitioner. Reimbursement for psychological Diagnostic Services is included in the per diem and will not be reimbursed for separately.4.Medically Necessary Pharmaceutical Services: If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside licensed/certified facility. All medications must be stored in a special locked storage space and administered only by a physician, registered nurse, or licensed practical nurse.5.Medically Necessary Dietary Services: If meals are provided by a day treatment program, services must be supervised by a registered dietitian, based on the client's individualized medical diet needs. The program may contract for these services through an outside licensed certified facility.6. Transition and discharge planning must meet the requirements of 471 NAC 20001.18. 20-003.01BOptional Services: The program must provide two of the following optional services. The client must have a need for the services, a supervising practitioner must order the services, and the services must be a part of the client's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy. In appropriate circumstances, occupational therapy may be covered if prescribed as an activities therapy in a psychiatric program: 1. Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a licensed/certified professional as listed below: d. Vocational Skills Therapy;e. Self-Care Services: Services supervised by a registered nurse or occupational therapist who is oriented toward activities of daily living and personal hygiene. This includes toileting, bathing, grooming, etc.2. Social Work provided by a bachelor's level social worker: Social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment, i.e., case management type services.3. Social Skills Building;20-003.01CSpecial Treatment Procedures in Day Treatment: If a client needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in day treatment are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Facilities must meet the following standards regarding special treatment procedures:
1. De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;2. Special treatment procedures may be used only when a client's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; and3. The client's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring LTO or physical restraints. These standards must be reflected in all aspects of the treatment program. Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.
003.02Standards for Participation20-003.02AProvider Standards: Providers of day treatment services shall meet the following standards: 1.Non-Hospital Based Day Treatment: A center providing day treatment must be - a. Appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health; andb. Accredited by JCAHO, CARF, COA, or AOA.2.Hospital Based Day Treatment: A hospital providing on-site day treatment must - a. Be licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health;b. Be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or AOA;c. Meet the requirements for participation in Medicare; andd. Have in effect a utilization review plan applicable to all Medicaid clients. When hospitals provide services in freestanding facilities, the freestanding facility must be appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health.
20-003.02BService Standards: 1. The program must provide a minimum of three hours of services five days a week, which is considered a half day for billing purposes. A minimum of six hours a day is considered a full day of service. Services may not be prorated for under three (or six) hours of services;2. A designated supervising practitioner must be responsible for the psychiatric care in a day treatment program. The supervising practitioner must be present on a regularly-scheduled basis and must assume clinical responsibility for all patients. If the supervising practitioner is present on a part-time basis, one of the following shall assume delegated professional responsibility for the program and must be present at all times when the program is providing services: b. A licensed psychologist;c. Licensed Independent Mental Health Practitioner; ord. An allied health therapist;3. Any supervising practitioner may refer a client to a day treatment program, but all treatment must be prescribed and directed by the program supervising practitioner;4. All treatment must be conducted under the supervision of the supervising practitioner in charge of the program;5.Psychotherapy Staff: See 471 NAC 20-001 for definitions. b. Licensed Psychologist;c. Licensed Independent Mental Health Practitioner; andd. Allied health therapists. All psychotherapy services provided by allied health therapists must be prescribed by the supervising practitioner and provided under his/her supervision. The supervising practitioner's personal involvement in all aspects of the client's psychiatric care must be documented in the client's medical record (i.e., physician's orders, progress notes, nurses notes).6. Admission Criteria: The following criteria must be met for a client's admission to a psychiatric day treatment program: a. The client must have sufficient medical need for active psychiatric treatment at the time of admission to justify the expenditure of the client's and program's time, energy, and resources; andb. Of all reasonable options for active psychiatric treatment available to the client, treatment in this program must be the best choice for expecting a reasonable improvement in the client's psychiatric condition.7. Pre-Admission Evaluation: The need for this level of care must be recommended on the pre-treatment assessment or addendum. Before the client is admitted to the program, the supervising practitioner shall complete an Initial Diagnostic Interview to validate the appropriateness of care. When a client is transferred from inpatient hospital care to day treatment, the inpatient evaluation and discharge summary documenting the rationale of transfer as part of the treatment plan serves the same purpose as the Initial Diagnostic Interview. The evaluation must be filed in the client's medical record. The preadmission evaluation must include - a. A clinical assessment of the health status and related psychological, medical, social, and educational needs of the client; andb. A determination of the range and kind of services required. The supervising practitioner shall personally complete an Initial Diagnostic Interview which must be used to develop the plan of care if all admission criteria have been met;
8. Treatment Plan: The program supervising practitioner shall determine the psychiatric diagnosis and prescribe the treatment, including the modalities and the professional staff to be used. He/she must be responsible and accountable for all evaluations and treatment provided to the client. The goals and objectives documented on the treatment plan must reflect the recommendations included in the Pre-treatment Assessment and the integration of input from 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 treatment plan shall be completed upon the client's admission to the program;
9. At least every 30 days thereafter, a treatment plan review must be conducted by the multi-disciplinary team, including the supervising practitioner. The treatment plan review must be documented on the Department approved treatment planning document (if required), and in the treatment plan. The facility's treatment plan review format, if approved by the Department, may function as the Department approved treatment planning document. The Department approved treatment planning document must be signed by the program supervising practitioner for day treatment services;
10. The supervising practitioner must personally evaluate the client every 30 days, or more often, as medically necessary. This evaluation must occur in a one-to-one, face-to-face session separate from the treatment plan review;11. Every 30 days a utilization review must be conducted per 471 NAC 20-003.07. This review must be documented on the Department approved treatment planning document (if required) and the facility's treatment plan review form. Utilization review is not required for the calendar month in which the client was admitted;12. The program must have a description of each of the services and treatment modalities available. This includes psychotherapy services, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other psychiatric day treatment services. a. The program must have a description of how the family-centered requirement in 471 NAC 20-001 will be met, including a complete description of any family assessment and family psychotherapy services. 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.
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.
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;
b. The program must have a description of how the community-based requirement in 471 NAC 20-001 will be met;c. The program shall state the qualifications, education, and experience of each staff member and the therapy services each provides.;d. The program must have a daily schedule covering the total number of hours the program operates per day. The schedule must be submitted to the Department for approval. The program must be fully staffed and supervised during the time the program is available for services, and must provide at least three hours of approved treatment for each day services are provided. This schedule must be updated annually, or more frequently if appropriate;13. Outpatient Observation: When appropriate for brief crisis stabilization, outpatient observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used as follows: An outpatient is defined as a person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone). If a patient receives 24 or more hours of continuous outpatient care, that patient is defined as an inpatient regardless of the hour of admission, whether s/he used a bed and whether s/he remained in the hospital past midnight or the census-taking hour, and all inpatient medical review prior-authorization requirements apply;
14. The program must have a written plan for immediate admission or readmission for appropriate inpatient psychiatric services, if necessary. The written plan must include a cooperative agreement with a psychiatric hospital or distinct part of a hospital, as outlined in 471 NAC 20-007. A copy of this agreement must accompany the provider application and agreement.003.03Provider Agreement A provider of psychiatric day treatment services shall complete a provider agreement and submit the form to the Department for approval. The provider shall attach to the provider application and agreement a written overview of the program including philosophy, objectives, policies and procedures, confirmation that the requirements in 471 NAC 20-001 and 471 NAC 20-002 are met and any other information requested by Medicaid staff. Staff must meet the standards outlined in 471 NAC 20-001.13; and:
1. Community mental health programs and licensed mental health clinics shall complete Form MC-19, "Medical Assistance Provider Agreement," and submit the completed form to the Department for approval. A Department approved cost reporting document (FA-20) must also be submitted. The provider application and agreement must be renewed annually to coincide with the submittal of the cost report. Satellites of community mental health programs shall bill the Department through their main community mental health program, unless the satellite has a separate provider number under Medicare. A satellite of a community mental health program that has a separate provider number under Medicare shall complete a separate provider agreement. All claims submitted to the Department by these satellites must be filed under the satellite's Medicaid provider number. The facility must have in effect a utilization review plan applicable to all Medicaid clients.2. Hospitals shall complete Form MC-20, "Medical Assistance Hospital Provider Agreement," and submit the completed form to the Department for approval. A Department approved cost reporting document (FA-20) must also be submitted. 20-003.03AAnnual Update: The program shall update the provider agreement, program overview, and cost report annually and whenever requested by the Division of Medicaid and Long-Term Care.003.04Coverage Criteria for Day Treatment Psychiatric Services The Nebraska Medical Assistance Program covers psychiatric day treatment services for clients 21 and over when the services meet the requirements in 471 NAC 20-001.
The client must be observed and interviewed by the program supervising practitioner at least every 30 days or more frequently if medically necessary and the interaction must be documented in the client's medical record.
20-003.04AServices Not Covered Under Medicaid: Payment is not available for psychiatric day treatment services for clients - 1. Receiving services in an out-of-state facility, except as outlined in 471 NAC 1002, Services Provided Outside Nebraska;2. Living in long term care facilities or Institutes for Mental Disease;3. Whose needs are social or educational and may be met through a less structured program;4. Whose primary diagnosis and functional impairment is psychiatric in nature but is not stable enough to allow them to participate in and benefit from the program; or5. Whose behavior may be very disruptive and/or harmful to other program participants or staff members.003.05Documentation in the Client's Clinical Record All documents submitted to Medicaid must contain sufficient information for identification (i.e., client's name, dates of service, provider's name) and must be legible. Each client's clinical record must contain the following documentation:
1. The supervising practitioner's orders;2. The Initial Diagnostic Interview and referral documented by the supervising practitioner;4. The team progress notes, recorded chronologically. The frequency is determined by the client's condition, but the team's progress notes must be recorded at least weekly. The progress notes must contain a concise assessment of the client's progress and recommendations for revising the treatment plan, as indicated by the client's condition, and discharge planning;5. Documentation indicating compliance with all requirements in 471 NAC 20-001;6. The program's utilization review committee's abstract or summary; and7. The discharge summary.003.06Transition and Discharge Planning Each provider must meet the 471 NAC 20-001 requirements for transition and discharge planning.
003.07Utilization Review (UR) Each program is responsible for establishing a utilization review plan and procedure which meets the following guidelines. A site visit by Medicaid staff for purposes of utilization review may be required for further clarification.
20-003.07AComponents of UR: Utilization review must provide - 1. Timely review (at least every 30 days) of the medical necessity of admissions and continued treatment;2. Utilization of professional services provided;3. High quality patient care; and4. Effective and efficient utilization of available health facilities and services. 20-003.07BUR Overview: An overview of the program's utilization review process must be submitted with the provider application and agreement before the program is enrolled as a Medicaid provider. The overview must include - 1. The organization and composition of the utilization review committee which is responsible for the utilization review function;2. The frequency of meetings (not less than once a month);3. The type of records to be kept; and4. The arrangement for committee reports and their dissemination, including how the supervising practitioner is informed of the findings. 20-003.07CUR Committee: The utilization review committee must consist of a supervising practitioner and at least two mental health practitioners (as defined in 471 NAC 20-001). A licensed psychologist may replace one of the allied health staff members. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the client whose case is being reviewed. At the Department's discretion, an alternative plan for facilities that do not have these resources readily available may be approved.20-003.07DBasis of Review: The review must be based on - 1. The identification of the individual client by appropriate means to ensure confidentiality;2. The identification of the supervising practitioner;3. The date of admission;4. The diagnosis and symptoms;5. The supervising practitioner plan of treatment; and6. Other supporting materials (progress notes, test findings, consultations) the group may deem appropriate. 20-003.07EContents of Report: The written report must contain - 1. An evaluation of treatment, progress, and prognosis based on - a. Appropriateness of the current level of care and treatment;b. Alternate levels of care and treatment available; andc. The effective and efficient utilization of services provided;2. Verification that - a. Treatment provided is documented in the client's record;b. All entries in the client's record are signed by the person responsible for entry. The supervising practitioner shall sign all orders; andc. All entries in the client's record are dated;3. Recommendations for - b. Alternate treatment/level of care; andc. Disapproval of continued treatment.4. The date of the review;5. The names of the program utilization review committee members; and6. The date of the next review if continued treatment is recommended. A copy of the admission review and the extended stay review must be attached to all claims for psychiatric services submitted to the Department for payment.
003.08Payment for Psychiatric Day Treatment Services Payment for psychiatric day treatment services will be based upon rate setting by the Department.
Payment rates for psychiatric day treatment services for individuals age 21 and older will be on a unit basis. Rates are set annually, for the period July 1 through June 30. Rates are set prospectively for this period, and are not adjusted during the rate period.
Providers are required to report their costs on an annual basis. Providers may choose any fiscal year end that they desire. Providers desiring to enter the program who have not previously reported their costs, or that are newly operated, are to submit a budgeted cost report, estimating their anticipated annual costs.
Providers shall submit cost and statistical data on Form FA-20. The provider shall submit one original Form FA-20 to the Department within 90 days of the close of fiscal year, or change in ownership or management. One 15-day extension may be granted under extenuating circumstances if requested, in writing, prior to the date. Providers shall compile data based on generally accepted accounting principles and the accrual method of accounting based on the provider's fiscal year. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by the Department for verification. If the provider fails to file a cost report as due, the Department will suspend payment. At the time the suspension is imposed, the Department will send a letter informing the provider that no further payment will be made until a proper cost report is filed.
In setting payment rates, the Department will consider those costs which are reasonable and necessary for the active treatment of the clients being served. Such costs will include those necessary for licensure and accreditation, meeting all staffing standards for participation, meeting all service standards for participation, meeting all requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care requirements and discharge planning.
The Department does not guarantee that all costs will be reimbursed. The Form FA-20 cost reporting document is used by the Department only as a guide in the rate setting process. Actual costs incurred by the providers may not be entirely reimbursed.
20-003.08APayment Rates for Psychiatric Day Treatment Services Provided by State-Operated Facilities: Psychiatric day treatment centers operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation, excluding educational services. State-operated centers will receive an interim payment rate, with an adjustment to actual costs following the cost reporting period.20-003.08BUnallowable Costs: The following costs are not allowable: 1. Provisions for income tax;2. Fees paid board of directors;3. Non-working officers' salaries;4. Promotion expense, except for promotion and advertising as allowed in HIM-15. Yellow Page display advertising is not allowable; one Yellow Page informational listing is allowable;5. Travel and entertainment, other than for professional meetings and direct operations of the day treatment program. This may include costs of motor homes, boats, and other recreational vehicles, including operation and maintenance expenses; real property used as vacation facilities; etc.;7. Expenses of non-related facilities and operations included in expense;8. Insurance and/or annuity premiums on the life of officer or owner;9. Bad debts, charity, and courtesy allowances;10. Cost and portions of costs which are determined by the Department not to be reasonably related to the efficient production of service because of either the nature or amount of the particular expenditure;12. Services provided by the clients' physicians or dentists, drugs, laboratory services, radiology services, or services provided by similar independent licensed providers, except services provided by state operated facilities. These exclusions are paid separately;14. Costs for services which occurred in a prior or subsequent fiscal year are unallowable;15. Expenses for equipment, facilities, and programs (e.g., recreation, trips) provided to clients which are determined by the Department not to be reasonably related to the efficient production of service because of either the nature or amount of the particular service;16. Costs of amusements, social activities, and related expenses for employees and governing body members are unallowable, except when part of an authorized client treatment program;17. Costs of alcoholic beverages are unallowable;18. Costs resulting from violations of, or failure to comply with federal, state, and local laws and regulations are unallowable;19. Costs relating to lobbying or attempts to influence/promote legislative action by local, state, or federal government are unallowable; and20. Costs of lawsuits or other legal or court proceedings against the Department, or its employees, or State of Nebraska are unallowable. 20-003.08CSuspension or Termination of License: The Department does not make payment for care provided after 30 days following the date of expiration or termination of the provider's license or certificate to operate under Title XIX. The Department does not make payment for care provided to individuals who were admitted after the date of expiration or termination of the provider's license or certificate to operate under Title XIX.20-003.08DAppeal Process: Final administrative decision or inaction in the rate setting process is subject to administrative appeal. The provider may request an appeal, in writing, from the Director for a hearing within 90 days of the decision or inaction. Regulations for appeals and fair hearings are contained in 465 NAC 2-001.02 and 2-006 ff.20-003.08EAdministrative Finality: An administrative decision or inaction in the allowable cost determination process, which is otherwise final, may be reopened by the Department within three years of the date of notice of the decision or inaction. "Reopening" is an action taken by the Director to re-examine or question the correctness of a determination or decision which is otherwise final. The Director is the sole authority for deciding whether to reopen an administrative decision or inaction. The action may be taken -
1. On the initiative of the Department within the three-year period;2. In response to a written request of a provider or other entity within the three-year period. Whether the Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with any law, regulations and rulings, or general instructions; or3. Any time fraud or abuse is suspected. A provider has no right to appeal a finding by the Director that a reopening or correction of a determination or decision is not warranted.
003.09Record Retention The provider shall retain financial records, supporting documents, statistical records, and all other pertinent records related to the cost report for a minimum of five years after the end of the report period. The Department shall retain all cost reports for at leave five years after receipt from the provider.
003.10Billing Requirements For day treatment services, the following requirements must be met:
1. Providers of non-hospital based day treatment services shall submit claims for day treatment 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 day treatment services is made to the facility.
2. Providers of hospital based day treatment services shall submit claims for services on an appropriately completed Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). Payment for approved hospital based day treatment services is made to the hospital.
20-003.10ADocumentation for Claims: The following documentation, kept in the client's file, is required for all claims for day treatment services: 1. Initial Diagnostic Interview;2. Supervising practitioner orders;4. Progress notes for all disciplines. All claims are subject to utilization review by the Department prior to payment. Reimbursement may be denied if claims and/or documentation are illegible (see 471 NAC 20-001.19).
20-003.10BException: Additional documentation from the client's medical record may be requested by the Department prior to considering authorization of payment. Progress notes for other Medicaid clients may be requested when the treatment report does not adequately explain family psychotherapy or medical necessity cannot be determined.003.11Procedure Codes and Descriptions for Psychiatric Day Treatment HCPCS/CPT procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-532).
003.12Costs Not Included in the Day Treatment Fee The mandatory and optional services are considered to be part of the fee for day treatment services. The following charges can be reimbursed separately from the day treatment fee when the services are necessary, part of the client's overall treatment plan, and in compliance with NMAP policy:
1. Direct client services performed by the supervising practitioner;2. Prescription medications (including injectable medications);3. Direct client services performed by a physician other than the supervising practitioner; and4. Treatment services for a physical injury or illness provided by other professionals. If the client is enrolled with another managed care vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity.
471 Neb. Admin. Code, ch. 20, § 003