N.J. Admin. Code § 10:66-2.7

Current through Register Vol. 56, No. 9, May 6, 2024

Section 10:66-2.7 - Mental health services

(a) Mental health services shall include comprehensive intake evaluation, individual psychotherapy, off-site crisis intervention, family therapy, family conference, group psychotherapy, psychological testing, partial care, and medication management. Mental health services shall not include:

1. Student education, including preparation of school-assigned classwork or homework; or

2. Incentive programs, including, but not limited to, non-therapeutic token economies and subcontract work responsibilities.

(b) Only one type of mental health service per beneficiary shall be reimbursable to an independent clinic per day, with the following exceptions:

1. Medication management may be reimbursed when provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary in addition to one of the following mental health services: assessment, individual psychotherapy, group psychotherapy, family therapy, and family conference.

2. Individual, group, or family psychotherapy services may be provided on the same date of service, but are limited to one unit each of individual psychotherapy, group psychotherapy, family therapy, or family conference. A maximum of three individual or group psychotherapy sessions may be provided per day, but are limited to five units per week. The provision of multiple services in one day is meant to supplant the need for partial care services and may not be billed on the same date of service as partial care.

3. An assessment may be completed on the same date of service as individual, group, or family therapy, but shall count toward the total of three units per day and five units per week.

4. Evaluation and management by a physician or APN may be provided concurrently with assessment or psychotherapy services and shall not count toward the total of three units per day or five units per week.

(c) Mental health clinics shall provide mental health services by, or under the direction of, a psychiatrist.

(d) For purposes of partial care, full day means five or more hours of participation in active programming exclusive of meals, breaks and transportation; half day means at least three hours but less than five hours of participation in active programming exclusive of meals, breaks and transportation. The smallest unit of partial care that may be prior authorized by NJ Medicaid/FamilyCare is one hour, with a minimum of two hours per day and a maximum of five hours per day. For example, prior authorization for a full day of partial care (five hours) shall be reflected as five units, four hours shall be reflected as four units, a half day (three hours) shall be reflected as three units, and two hours shall be reflected as two units. Additional details are located at N.J.A.C. 10:66-6.

(e) (Reserved.)

(f) The Division shall reimburse a provider for prevocational services provided within the context of a partial care program. Prevocational services shall be interventions, strategies, and activities, within the context of a partial care program, that assist individuals to acquire general work behaviors, attitudes, and skills needed to take on the role of worker and in other life domains, such as responding appropriately to criticism, decision making, negotiating for needs, dealing with interpersonal issues, managing psychiatric symptoms, and medication adherence. Services or interventions which are not considered prevocational will not be reimbursed by the Medicaid and NJ FamilyCare programs. Examples of services or interventions not considered to be prevocational include:

1. Technical or occupational skills training;

2. College preparation;

3. Student education, including preparation of school-assigned classwork or homework; and

4. Individualized job development.

(g) The Division will not reimburse any provider for vocational services provided within the context of a partial care program.

1. Vocational services shall be those interventions, strategies, and activities that assist individuals to acquire skills to enter a specific occupation and take on the role of colleague, that is, a member of a profession, and/or assist the individual to directly enter the workforce and take on the role of an employee, working as a member of an occupational group for pay with a specific employer.

(h) When, in the judgment of the treatment team, an individual is determined appropriate for discharge or referral to another employment-related service provider or situation, and has demonstrated mastery of individualized goals and objectives, such as: an ability to respond appropriately to criticism, make decisions, negotiate for needs, deal with interpersonal issues, manage psychiatric symptoms and adhere to medical prescriptions, the service provider shall:

1. Update the individual treatment goal;

2. Revise the discharge plan; and

3. Refer the individual to a community work setting, if such referral is appropriate for the individual.

(i) The Division will reimburse a provider for prevocational services provided to eligible beneficiaries within the context of a partial care program when the services consist of therapeutic subcontract work activity, and when all of the following requirements are met:

1. The therapeutic subcontract work activity shall consist of production, assembly and/or packing/collating tasks for which individuals with disabilities performing these tasks are paid less than minimum wage, and, pursuant to 29 C.F.R. § 525, a special minimum wage certificate has been issued to the organization/program by the U.S. Department of Labor;

2. The individual's plan of care shall contain a stipulation that the therapeutic subcontract work activity is a form of intervention intended to address the individual deficits of the patient as identified in the client's assessment;

3. The therapeutic subcontract work activity shall be facilitated by a qualified mental health services worker;

4. The therapeutic subcontract work activity shall be performed within the line of sight of the qualified mental health services worker; and

5. The staff to client ratio shall not exceed a ratio of 1:10 qualified mental health services worker to client.

(j) An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit, whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that:

1. Evaluates the beneficiary's mental condition;

2. Determines whether treatment in the program is appropriate, based on the beneficiary's diagnosis;

3. Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary's treatment needs; and

4. Is made part of the beneficiary's records.

5. The evaluation for the intake process shall include a physician or an advanced practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified.

(k) A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary's condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary's records and shall consist of:

1. A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives.

i. Due to the nature of mental illness and the provision of program services, there may be instances in which a temporary deviation from the services written in the treatment plan occurs. In this event, the client may participate in alternate programming. The reason for the deviation should be clearly explained in the daily or weekly documentation. Deviations that do not resolve shall require a written change in the treatment plan;

2. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter;

3. The type of personnel that will be furnishing the services; and

4. A projected schedule for completing reevaluations of the beneficiary's condition and updating the plan of care.

(l) The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made.

1. This documentation, at a minimum, shall consist of:

i. The specific services rendered, such as individual psychotherapy, group psychotherapy, family therapy, etc., and a description of the encounter itself. The description shall include, but is not limited to, a statement of patient progress noted, significant observations noted, etc.;

ii. The date and time that services were rendered;

iii. The duration of services provided;

iv. The signature of the practitioner or provider who rendered the services;

v. The setting in which services were rendered; and

vi. A notation of unusual occurrences or significant deviations from the treatment described in the plan of care.

2. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary's medical record at least once a week, as well as any other information important to the clinical picture, therapy, and prognosis.

3. The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week.

(m) Periodic review of the beneficiary's plan of care shall take place at least every 90 days during the first year and every six months thereafter.

1. The periodic review shall determine:

i. The beneficiary's progress toward the treatment objectives;

ii. The appropriateness of the services being furnished; and

iii. The need for the beneficiary's continued participation in the program.

2. Periodic reviews shall be documented in detail in the beneficiary's records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.

(n) When requesting reimbursement for the following HCPCS procedure codes for rehabilitative services, a separate service line shall be completed for each day that the service is provided. Providers shall not "span bill" for services.

90870

N.J. Admin. Code § 10:66-2.7

Amended by 49 N.J.R. 1405(a), effective 6/5/2017