N.Y. Comp. Codes R. & Regs. tit. 14 § 599.14

Current through Register Vol. 46, No. 45, November 2, 2024

Section 599.14 - Medical assistance billing standards

(a) Medicaid claims for individuals who have been admitted to a Mental Health Outpatient Treatment and Rehabilitative Service program shall include, at a minimum, the Medicaid identification number of the individual, the designated mental illness diagnosis, the procedure code or codes corresponding to the procedure or procedures provided, the location of the service, specifically the licensed location where the service was provided or the clinician's regular assigned licensed location from which the clinician departed for an off-site procedure, and the National Provider Identification or equivalent Department of Health-approved alternative as appropriate of the attending clinician. The provider must also comply with the requirements associated with any procedure code being billed.

(b) Medicaid claims may be reimbursed for up to three pre-admission procedures per adult individual, excluding Peer/Family Support Services which has no pre-admission reimbursement limit, no more than one of which may be a collateral procedure. For children, claims may be reimbursed for up to three pre-admission visits per child/family, excluding visits solely for Peer Support Services. For pre-admission visits at least the code for unspecified Illness must be entered on the claim.

(c) Medicaid claims may be submitted for no more than three services, comprising of two psychiatric services and one health service, per day for any individual, not including crisis intervention, complex care management, peer support services, or any services that are provided as part of IOP. For the purposes of this subdivision, psychotropic medication treatment, injectable psychotropic medication administration, injectable psychotropic medication administration with monitoring and education, and complex care management services may be counted as either health services or psychiatric services. No more than one health physical may be claimed in one year.

(d) Billing services.

(1) Assessment services consist of two types of assessment--Initial Assessment and Psychiatric Assessment. No more than three initial assessment procedures may be reimbursed by Medicaid. Additional initial assessment procedures are eligible for Medicaid reimbursement when more than 365 days have transpired since the most recent Medicaid reimbursed visit to the Mental Health Outpatient Treatment and Rehabilitative Service program.

(i) initial assessment Services shall include performance or consideration, as applicable, of the Health Screening.

(ii) The Mental Health Outpatient Treatment and Rehabilitative Service program must document a minimum of 45 minutes face-to-face contact with the individual or family or other collaterals. For school-based services, the duration of such services may be that of the school period, provided the school period is of a duration of at least 40 minutes.

(iii) Mental Health Outpatient Treatment and Rehabilitative Service programs may bill the physician modifier when psychiatrists, nurse practitioners in psychiatry, or physicians approved pursuant to Section 599.9 of this Part spend at least 15 minutes serving the individual during the time the initial assessment is being conducted by another licensed practitioner.

(iv) A Psychiatric Assessment may be provided to either an individual being assessed for admission to the Mental Health Outpatient Treatment and Rehabilitative Service program, or an individual who is currently admitted. Psychiatric assessments may be performed for admitted recipients where medically necessary without limitations. Psychiatric Assessments may include such elements as a diagnostic interview and treatment plan development.

(a) A Psychiatric Assessment may be provided by a physician, psychiatrist, nurse practitioner in psychiatry, or physician assistant with specialized training approved by the Office to an individual who has been admitted to the Mental Health Outpatient Treatment and Rehabilitative Service program, or one for whom the appropriateness of admission is being assessed.

(b) A Psychiatric Assessment of at least 30 minutes of documented face-to-face interaction between the individual, or family or other collaterals, and the physician, psychiatrist, or nurse practitioner in psychiatry, shall be billed as a Brief Psychiatric Assessment.

(c) A Psychiatric Assessment of at least 45 minutes of documented face-to-face interaction between the individual, or family or other collaterals, and the physician, psychiatrist or nurse practitioner in psychiatry, shall be billed as an Extended Psychiatric Assessment.

(d) Programs shall comply with the most recent applicable AMA coding guidelines regarding the appropriate use of evaluation and management codes for Psychiatric Assessment services, including minimum duration standards for the provision of psychotherapy services provided by physicians and nurse practitioners. Where clinically appropriate and consistent with applicable AMA coding guidelines for service duration ranges for evaluation and management codes, programs may bill for Brief or Extended Psychiatric Assessments for shorter service durations than those specified in this subparagraph.

(2) Psychiatric Consultation.

(i) Psychiatric Consultation may be provided by a Physician, Psychiatrist, Nurse practitioner, or Psychiatric nurse practitioner to a referring physician for the purposes of assisting in the diagnosis, integration of treatment, or assistance in ensuring continuity of care, for a n individual receiving services from a referring physician.

(ii) Psychiatric Consultation services must be face-to-face with the individual, or using telehealth, where approved by the Office and shall be billed by the Program in the same manner as Psychiatric Assessments pursuant to paragraph (1) of this subdivision.

(3) Crisis Intervention.

(i) The Mental Health Outpatient Treatment and Rehabilitative Service program may make contractual arrangements for after-hours crisis coverage by clinicians, but contracts for this service must be approved by the local governmental unit in which the Mental Health Outpatient Treatment and Rehabilitative Service program is located, or by the Office for county-operated Mental Health Outpatient Treatment and Rehabilitative Service programs.

(ii) Crisis Intervention Services consist of three billable levels of service.

(a) Crisis Intervention--Brief. Brief Crisis Intervention Services shall be done in person or via telehealth. For services of a duration of at least 15 minutes, one unit of service shall be billed. For each additional service increment of at least 15 minutes, an additional unit of service may be billed, up to a maximum of six units per day.

(b) Crisis I ntervention--Complex. Complex Crisis Intervention requires a minimum of one hour of face-to-face contact by two or more clinicians. Both clinicians must be present for the majority of the duration of the total contact. Certified Peer Specialists, Credentialed Family Peer Advocates, and Credentialed Youth Peer Advocates, or paraprofessional staff may substitute for one clinician. Mental Health Outpatient Treatment and Rehabilitative Service program may be reimbursed for crisis intervention-complex services provided to individuals who have not engaged in services for a period of up to two years.

(c) Crisis I ntervention--Per Diem. Per Diem Crisis Intervention requires three hours or more of face-to-face contact by two or more clinicians. Both clinicians must be present for the majority of the duration of the total contact. Certified Peer Specialists, Credentialed Family Peer Advocates, and Credentialed Youth Peer Advocates, or paraprofessional staff may substitute for one clinician. Mental Health Outpatient Treatment and Rehabilitative Service programs may be reimbursed for crisis intervention-per diem services provided to individuals who have not engaged in services for a period of up to two years.

(4) Injectable Psychotropic Medication Administration services are reimbursed for in person contact between a clinician and the individual. Injectable Psychotropic Medication Administration Services consist of two billable levels of service.

(i) Injectable Psychotropic Medication Administration service has no minimum time limit. This service includes medication injection.

(ii) Injectable Psychotropic Medication Administration with Monitoring and Education requires a minimum of 15 minutes. This service includes medication injection, monitoring and individual education, as necessary. If the Injectable Psychotropic Medication Administration with Monitoring and Education Service is provided to an individual by a Psychiatrist, Physician, Nurse practitioner, or Psychiatric Nurse Practitioner, it shall not be claimed in addition to an evaluation and management service (including psychiatric assessment and psychotropic medication treatment) received by that individual on the same day. In this case, the Mental Health Outpatient Treatment and Rehabilitative Service program may claim reimbursement for an Injectable Psychotropic Medication Administration procedure instead.

(5) Psychotropic Medication Treatment services are reimbursed for face-to-face contact of at least 15 minutes in duration between a Psychiatrist, Physician, Nurse practitioner, or Psychiatric Nurse Practitioner, and the individual.

(6) Psychotherapy services. Psychotherapy services consist of the following levels of billable service.

(i) Psychotherapy services individual shall be reimbursed as follows:

(a) A psychotherapy service provided face to face with the individual with a documented duration of 30 minutes shall be billed as a brief psychotherapy service.

(b) A psychotherapy service provided face to face with the individual with a documented duration of 45 minutes shall be billed as an extended psychotherapy service.

(c) Brief and Extended Psychotherapy services may be billed where more than half of the minimum service duration is spent providing services to the individual and the remainder of the minimum service duration is spent providing service to a collateral.

(d) Programs shall comply with applicable AMA coding guidelines regarding the appropriate use of evaluation and management codes for Psychotherapy services. Where clinically appropriate and consistent with applicable AMA coding guidelines for service duration ranges for evaluation and management psychotherapy codes, programs may bill for Brief or Extended Psychotherapy for shorter service durations than those specified in this subparagraph.

(ii) Psychotherapy Family/Collateral with the individual requires documented cumulative, continuous face-to-face service with the individual and the collateral of a minimum duration of 50 minutes, during which time the individual shall be present for at least the majority of the time.

(iii) Psychotherapy Family/Collateral Without the individual requires documented face-to-face service with the collateral of a minimum duration of 30 minutes. For this service, the individual may also be present for some or all of the time. Where clinically appropriate and consistent with applicable AMA coding guidelines for service duration ranges for evaluation and management psychotherapy codes, programs may bill for Psychotherapy-Family/Collateral Without the Individual for shorter service durations than those specified in this subparagraph.

(iv) Psychotherapy Multi- Individual Group requires documented face-to-face service with a minimum of two recipients and a maximum of 12 recipients for services of a minimum duration of 60 minutes. For services of a duration of at least 40 minutes and less than 60 minutes, reimbursement will be reduced by 30 percent.

(v) Psychotherapy Multi-Family/Collateral Group requires documented face-to-face service with a minimum of two multifamily/ collateral units and a maximum of eight multifamily/ collateral units in the group, with a maximum total number in any group not to exceed 16 individuals, and a minimum duration of 60 minutes of service. For services of a duration of at least 40 minutes and less than 60 minutes, reimbursement will be reduced by 30 percent.

(7) Testing Services, including Developmental Testing, Neurobehavioral Status Examination, and Psychological Testing. Medical Assistance may reimburse for this service solely for individuals admitted to the Mental Health Outpatient Treatment and Rehabilitative Service program. Developmental Testing services must be face-to-face with the individual.

(8) Complex care management must be provided no later than within 14 calendar days following a face-to-face psychotherapy, psychotropic medication treatment, or crisis intervention mental health outpatient program service. A maximum of four units of at least five consecutive minutes of complex care management may be billed following each face-to-face psychotherapy, psychotropic medication treatment, or crisis intervention service. Each full five-minute unit may be provided on separate days within the 14-calendar day limit, with a maximum of four full five-minute units associated with each eligible Mental Health Outpatient Treatment and Rehabilitative Service program visit. The time spent documenting the provision of complex care management or in other documentation activities shall not be included in the calculation of time for the purposes of billing of complex care management.

(9) Peer/Family Support Services may be provided to individuals, family or other collaterals, or groups of individuals not to exceed 12. For services of a duration of at least 15 minutes, one unit of service shall be billed. For each additional service increment of at least 15 minutes, an additional unit of service may be billed, up to twelve units per day, or 3 hours maximum. Multiple units of Peer/Family Support Services may be provided consecutively or at different times of the day.

(e) Modifiers. Billing modifiers, including modifiers paid as supplementary rates to visits, are available pursuant to this section as indicated in the modifier chart included in this subdivision.

Modifier Chart for Services Provided On-Site

Office of Mental Health Service Name	After Hours	Language other than English	Physician/ NPP
Complex Care Management	x	x
Crisis Intervention Service -brief	x	x
Crisis Intervention Service - Complex	x	x
Crisis Intervention Service - Per Diem	x	x
Peer/Family Support Services	x	x
Developmental, Neurobehavioral Status Exam, and Psychological Testing	x	x
Injectable Psychotropic Medication Administration with Monitoring and Education	x	x
Psychotropic Medication Treatment	x
Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development	x	x	x
Psychiatric Assessment - brief	x	x
Psychiatric Assessment - extended	x	x
Individual Psychotherapy - brief	x	x	x
Individual Psychotherapy - extended	x	x	x
Group and Multifamily/Collateral Group Psychotherapy	x	x	x
Family Therapy/Collateral w/o patient	x	x	x
Family Therapy/Collateral with patient	x	x	x

(f) A Mental Health Outpatient Treatment and Rehabilitative Service program may not be reimbursed for services provided to an individual currently enrolled in another program licensed by the Office for which Medicaid reimbursement is being made except as provided in this subdivision.

(1) Reimbursement shall be made for up to three pre-admission visits when a n individual is in transition from another outpatient program, except another Mental Health Outpatient Treatment and Rehabilitative Service program. After completion of the three preadmission visits, a Mental Health Outpatient Treatment and Rehabilitative Service program provider may not bill Medical Assistance for a service unless it is medically necessary, performed pursuant to a treatment plan approved pursuant to this Part, and, except as specified in this subdivision, the individual has been discharged from the other outpatient program.

(2) Reimbursement shall be made for a n individual currently admitted to a continuing day treatment program in accordance with Part 587 of this Title when such individual shall also be admitted to a Mental Health Outpatient Treatment and Rehabilitative Service program solely for the purpose of clozapine medication therapy. Reimbursement shall be made for no more than five clozapine medication treatment visits per month per individual.

(3) Reimbursement shall be made for services provided, including preadmission visits, without regard to an individual's enrollment in more than one, different Mental Health Outpatient Treatment and Rehabilitative Service programs, except reimbursement shall not be made to more than one program for the same service on the same date of service.

(4) Reimbursement shall not be made for services rendered by a Mental Health Outpatient Treatment and Rehabilitative Service program to residents of a residential health care facility. Reimbursement shall be made to the Mental Health Outpatient Treatment and Rehabilitative Service program by the residential health care facility.

(g) The Office will only consider requests for revisions of fees calculated under the provisions of this Part due to errors made by the Office in its calculation.

(1) A request for revision of a fee calculated in accordance with this section shall be sent to the Commissioner by registered or certified mail and shall contain a detailed statement of the basis for the requested revision together with any documentation that the provider of service wishes to submit.

(2) A request for revision must be submitted within 120 days of receipt by the provider of service of the rate computation.

(3) The provider of service shall be notified in writing of the Commissioner's determination, including a statement of the reasons therefor.

(h) Miscellaneous billing rules.

(1) Services provided by Mental Health Outpatient Treatment and Rehabilitative Service programs operated by agencies licensed under article 28 of the Public Health Law, which are also licensed pursuant to article 31 of the Mental Hygiene Law, shall not be considered to be specialized services pursuant to section 2807 of the Public Health Law.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 599.14

Amended, New York State Register December 17, 2014/Volume XXXVI, Issue 50, eff. 12/17/2014

Amended, New York State Register April 1, 2015/Volume XXXVII, Issue 13, eff. 4/1/2015

Amended New York State Register November 23, 2022/Volume XLIV, Issue 47, eff. 11/23/2022