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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Medicaid Requirements for OMH-Licensed Outpatient Programs
NYS Office of Mental Health
January 2004

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Introduction

This document provides a summary of the requirements included in the NYS Office of Mental Health's outpatient regulations, as they pertain to receipt of Medicaid payments. These requirements have been extracted from 14 NYCRR Parts 587 and 588, which are applicable to clinic treatment programs, continuing day treatment programs, day treatment programs for children, intensive psychiatric rehabilitation treatment programs, and partial hospitalization programs. In some instances, additional guidance or clarification is provided. The document is organized into the following three sections:

The Eligibility section outlines the minimum requirements which must be met in order for a specific provider to be able to bill Medicaid on behalf of a specific individual, for a given service. The Billing section summarizes the basic billing rules and limitations. The Documentation section summarizes the requirements which, when met, provide supporting documentation that the eligibility and billing requirements have been met. Even when there is not a specific documentation requirement included in the regulations, providers are advised to ensure that they have sufficient documentation to verify compliance with other standards. There is no practice or approach that substitutes for thorough, accurate and timely record keeping.

Providers are advised that this document is not a substitute for a careful review of the applicable regulations. In the event of any conflict between this document and 14 NYCRR Parts 587 and 588, the regulations are controlling.

Providers are encouraged to maintain up-to-date copies of the regulations, and to ensure that they are accessible to relevant staff. The regulations are available on OMH's website at www.omh.state.ny.us/omhweb/policy_and_regulations/.

Eligibility for Reimbursement

Program Admission Criteria
Clinic Treatment Program designated mental illness diagnosis
Continuing Day Treatment Program designated mental illness diagnosis and dysfunction due to mental illness
Day Treatment Program for Children designated mental illness diagnosis, plus either an extended impairment in functioning due to emotional disturbance or a current impairment in functioning with severe symptoms
Intensive Psychiatric Rehabilitation Treatment Program designated mental illness diagnosis, dysfunction due to mental illness which is likely to continue for a prolonged time, readiness to participate in the program, and referral by a licensed practitioner
Partial Hospitalization Program designated mental illness diagnosis which has resulted in dysfunction due to acute symptomatology which requires medically supervised intervention to achieve stabilization and which, but for the availability of a partial hospitalization program, would necessitate admission to, or continued stay in, an inpatient hospital
Designated mental illness diagnosis is a DSM diagnosis (or ICD equivalent) other than: 1) alcohol or drug disorders; 2) developmental disabilities; 3) organic brain syndromes; 4) social conditions (V-Codes). V-Code 61-20 Parent-Child problem is included for eligibility for services in clinic treatment programs serving children with a diagnosis of emotional disturbance.
Note: While program activities can be described in multiple ways and many providers prefer to use local terminology, providers are advised, whenever practicable, to use the service labels included in the regulations to ensure that the meaning and intent of the service is understood by external reviewers. As an alternative, providers are advised to develop a "crosswalk", comparing provider terminology with regulatory language.
Note: While the person rendering the service may include a member of the professional staff, a non-professional member of the clinical staff, or an identified volunteer, such person should be reflected on the provider's staffing plan.
Clinical support services are services provided to collaterals, by at least one therapist, with or without recipients for the purpose of providing resources and consultation for goal oriented problem solving, assessment of treatment strategies and provision of skill development to assist the recipient in management of his or her illness.
Collateral persons are members of the recipient's family or household, or significant others who regularly interact with the recipient and are directly affected by or have the capability of affecting his or her condition and are identified in the treatment or psychiatric rehabilitation service plan as having a role in treatment and/or identified in the pre-admission notes as being necessary for participation in the evaluation and assessment of the recipient prior to admission. A group composed of collaterals of more than one recipient may be gathered together for purposes of goal-oriented problem solving, assessment of treatment strategies and provision of practical skills for assisting the recipient in the management of his or her illness.
Note: An individual cannot be considered a "collateral person" based on his or her role as a staff member of the outpatient program, or any other mental health service provider.
Program Visit Category & Duration
Clinic Treatment Program Pre-admission: 30+ minutes
Brief: 15 - 29 minutes
Regular: 30+ minutes
Crisis: 30+ minutes
Group: 60+ minutes
Collateral: 30+ minutes
Group collateral: 1 - 2 hours
Continuing Day Treatment Program Pre-admission: 1 hour+
1 - 5 hours (recipient visit)
Collateral: 30 minutes - 2 hours
Group collateral: 1 - 2 hours
Day Treatment Program for Children Pre-admission: 3 hours+
Full: 5+ hours
Half: 3 - 5 hours
Brief: 1 - 3 hours
Collateral: 30+ minutes
Home: 30+ minutes
Crisis: 30+ minutes
Intensive Psychiatric Rehabilitation Treatment Program Pre-admission: 1 hour+
1 - 5 hours
Partial Hospitalization Program Pre-admission: 1 hour+
4 - 7 hours (recipient visit)
Collateral: 30 minutes - 2 hours
Group collateral: 1 - 2 hours
Most Common Reasons for Medicaid Disallowances Associated with Eligibility
  • pre-admission visits exceed the limit
  • minimum duration of visit is not met

Billing Requirements and Limitations

Note: The mental illness diagnosis is not required to be the primary diagnosis. For pre-admission visits, "diagnosis deferred" (799.9) may be used.
* Note: A single visit can include multiple services, provided by multiple members of the clinical staff. Multiple, non-contiguous contacts during a single day may be aggregated for a single bill.
Note: Although co-enrollment is permitted in the above circumstances, visits to multiple programs cannot occur on the same day.
Program Rate Codes
Clinic Treatment Program 4301 - 4306
     COPs-Only* 4093 - 4098
     Interim Specialty Clinics* 4601 - 4606
Continuing Day Treatment Program 4307 - 4348
Day Treatment Program for Children 4060 - 4067
Intensive Psychiatric Rehabilitation Treatment Program 4364 - 4368
Partial Hospitalization Program 4349 - 4363

* For use on behalf of persons enrolled in Medicaid Managed Care. (Interim Specialty Clinics are also commonly referred to as "SED Clinics.")

Most Common Reasons for Medicaid Disallowances Associated with Billing
  • improper rate codes used
  • duplicate bills in the same day

Supporting Documentation

Note: The dates of service in this record must match the dates of service reflected in the Medicaid claim.
Note: Although some providers include this information in the progress notes, a separate service record may be maintained. Regardless of the approach used, providers should consider adopting a consistent approach by all clinicians throughout the program. Such consistency would aid the process of any external review.
Program Completion of Treatment/Service Plan
Clinic Treatment Program prior to the fourth visit after admission, or within 30 days of admission, whichever comes first
Continuing Day Treatment Program prior to the twelfth visit after admission, or within 30 days of admission, whichever comes first
Day Treatment Program for Children within 30 days of admission
Intensive Psychiatric Rehabilitation Treatment Program within five visits after admission
Partial Hospitalization Program prior to the fourth visit after admission
Program Treatment/Service Plan Reviews
Clinic Treatment Program every three months
Continuing Day Treatment Program every three months
Day Treatment Program for Children every three months
Intensive Psychiatric Rehabilitation Treatment Program every month
Partial Hospitalization Program every two weeks
Program Completion of Progress Notes
Clinic Treatment Program every visit
Continuing Day Treatment Program every two weeks
Day Treatment Program for Children every week
Intensive Psychiatric Rehabilitation Treatment Program N/A (part of monthly service plan review)
Partial Hospitalization Program every visit
Note: Treatment/service plans and related reviews, and progress notes, when signed, should be dated so that compliance with completion schedules can be tracked.
Program Utilization Review Schedule
Clinic Treatment Program within 30 days of admission, and every 6 months thereafter
Continuing Day Treatment Program by the 12th visit, or within 30 days of admission, and every 6 months thereafter
Day Treatment Program for Children within 30 days of admission, and every 6 months thereafter
Intensive Psychiatric Rehabilitation Treatment Program within 30 days of admission, and every 3 months thereafter
Partial Hospitalization Program by 4th visit after admission, and every 2 weeks thereafter
Most Common Reasons for Medicaid Disallowances Associated with Documentation
  • missing progress notes
  • missing physician signature on treatment plan
  • missing treatment plans
  • no indication of services provided
  • untimely completion/review of treatment plans
  • duration of visit not documented
  • missing case records