Continuing Day Treatment Programs
New Reimbursement Methodology
NEW additional/amended FAQs added 4/24/09
How will pre-admission visits be handled?
To implement the 2009/10 Budget as enacted OMH will have to amend the recently published emergency CDT regulations. These new regulations will include the assignment of a unique rate code for pre-admission billing. The emergency regulations recently published do not include pre-admission visit reimbursement details. The emergency regulations have been revised to clarify that pre-admission visits that meet the minimum duration of one hour may be billed as half-day visits; limited to three visits per recipient. Pre-admission visits do not count toward the tier assignment.
How do crisis, collateral and group collateral relate to regular CDT half day and full day visits? Does the full-day visit requirement of four hours of program attendance include time spent in crisis, collateral and group collateral services?
Crisis, collateral and group collateral services are separate and distinct services. Neither the time spent, nor the services received, are included in the minimum requirements to bill for either a regular half day or a full day CDT visit.
Multiple visits per day are permissible limited to:
- One recipient visit; either half day or full day regular CDT
- And one collateral visit; either individual or group
- And one or more crisis visit.
Some services may occur concurrently. Collateral visits are clinical support services between one or more collaterals and one therapist with or without a recipient. Therefore, if a collateral visit occurs without a recipient while the recipient separately attends the CDT program, the recipient’s time counts toward the half-day or full-day visit while the collateral’s time counts toward a collateral visit. If, however, the recipient is involved in the collateral service, such time cannot be counted toward the recipient’s regular CDT half-day or full-day visit.
How is time determined or accumulated for billing?
Only the actual time that a recipient is in attendance at the CDT program is counted. The time is not rounded. Meal times cannot be included as part of the minimum time required for program attendance.
- Which procedure code should I use for half day or full day billing?
The requirements for procedure codes have not changed. You may continue to bill using the procedure code(s) that you have successfully used in the past.
FAQs posted 3/2/2009
- Has the programmatic intent of continuing day treatment (CDT) programs changed as a result of the change to the reimbursement methodology?
- Although the Office of Mental Health (OMH) has changed the reimbursement methodology for CDT programs and has revised 14 NYCRR Part 588 accordingly, the programmatic intent of CDT programs has not changed and there are no revisions to 14 NYCRR Part 587 (Operation of Outpatient Programs) planned. Programs will be licensed and re-certified using the same standards and process as before, except in regard to the minimum number of required services. As currently stated in 587.10(a), “a continuing day treatment program shall provide active treatment designed to maintain or enhance current levels of functioning and skills, to maintain community living, and to develop self-awareness and self-esteem through the exploration and development of strengths and interests.”
As before, CDT programs should reflect a recovery model that advances the independence of the individuals enrolled and should demonstrate a person-centered approach to assist consumers in achieving their stated life goals. CDT programs should be designed to assist individuals in managing their mental health condition, restoring skills, addressing functional barriers related to life roles, and establishing or developing natural social supports and linkages in the community. Services and activities should present opportunities for consumer choice with high but attainable expectations for consumer participation.
The ultimate goal is for the individual receiving services to achieve desired life roles or goals such as, but not limited to, those related to securing or retaining employment, returning to school, being a parent or spouse, making friends, or accessing generic community resources to meet individual needs. Services should assist individuals in using their inherent strengths and supports to overcome barriers to goal achievement that are caused by their mental health condition.
- The Medicaid reimbursement methodology for CDT programs has been revised to reflect a half-day/full-day visit approach. To bill for a half-day visit requires the provision of at least one medically necessary service during a minimum of two hours of program attendance. To bill for a full-day visit requires the provision of at least three medically necessary services during a minimum of four hours of program attendance. While a minimum number of medically necessary services are required in order to bill, the programmatic expectation remains that consumers are participating in active treatment and clinically appropriate services that foster recovery. Thus, it is anticipated that the total number of services provided to individuals each day will vary according to individual need.
- The previous methodology involved billing for visits, based on duration, in one-hour increments. Visits were required to be a minimum of one hour and a maximum of five hours. Each visit was required to include at least one service. While the term “medically necessary service” was not previously mentioned in the regulations, the intent was reflected. That is, services were required to be in accordance with the individual's treatment plan, which is the essence of medical necessity.
- Although the CDT regulations did not previously include a reference to the term “medical necessity,” it is not a new concept, and has always applied to Medicaid-reimbursable services. In New York State, medical necessity is defined as follows:
“…care, services and supplies…which are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with that person's capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with this title and the regulations of the department." (NYS Social Services Law 365-a(2))
In the context of CDT programs, the concept of medical necessity is closely associated with individualized service planning. That is, there must be a strong congruence between assessments and treatment plans. As part of the initial assessment, recipients must be determined to meet the program admission criteria (i.e., a designated mental illness diagnosis and a related dysfunction), and the initial and ongoing assessment process should identify the consumer's unique strengths, needs and goals. The resulting treatment plans should identify specific services (among those services that the CDT program is authorized to provide by virtue of its operating certificate pursuant to 14 NYCRR 587.10) to address symptom reduction needs, functional deficits, and maladaptive behaviors that impede the ability of the individual to achieve his or her life goals. Such services should be clinically appropriate in terms of type, frequency and extent, and should be considered effective in the context of the consumer's diagnosis and need. Treatment plans should be reviewed and modified to reflect progress, changes in the recipient's condition and any major life events. This ongoing process of matching specific services to a consumer's individualized goals is a reflection of the “medical necessity” concept.
- Program attendance means the time period that a recipient is in attendance at the CDT program. Meal times cannot be included as part of program attendance.
- Yes, providers need to provide some type of supporting documentation that confirms that attendance requirements were met on an individual basis. OMH does not dictate the form or format of that documentation.
- Except for the pre-existing minimum time requirements that are associated with collateral, group collateral, and pre-admission services, which are being maintained in the new methodology, there is no minimum time requirement associated with the provision of any given service. It is expected, however, that service duration will be consistent with the type of service provided, as well as the individual's goals, needs and current tolerance for active participation. While not required, it is common practice for group sessions to last for approximately 45 – 60 minutes.
Although providers are required to maintain documentation that reflects the period of overall program participation (i.e. duration of daily attendance), they are not required to document the duration of any individual service that does not have a minimum duration requirement. However, existing documentation requirements applicable to services remain in effect. That is, treatment plans must include the identification of specific services associated with achievement of specified goals, treatment plan reviews must identify time periods for goal achievement, and progress notes must identify the particular types of services that were provided during the time period covered by each note.
- During periods when individuals are in attendance at the CDT program but are not participating in formal treatment groups or other services as identified in the treatment plan, there should be additional, clinically appropriate, staff-directed, age-appropriate, meaningful activities offered that enhance recovery, create opportunities to learn and practice skills, reduce functional deficits and promote interaction. Examples of recovery-oriented activities include, but are not limited to, a group of consumers working independently to produce a newsletter, planning social activities that will occur after program hours, participation in a peer advisory group or a peer-run empowerment activity, developing a WRAP plan, or participating in self-help groups such as Double Trouble in Recovery. A key element of such activities is that consumers are actively engaged. It is expected that these activities will further support the goals and objectives identified in the treatment plan.
Participation in recovery-oriented activities that are not otherwise medically necessary may be either scheduled or spontaneous, but should not include program-wide social, recreational, or educational events such as movies, parties, outings, GED classes or meals. A program comprised primarily of diversionary activity, or social or recreational activities, does not constitute a CDT model. CDT programs should not be used as “drop-in” centers with little active interaction with CDT services. While it is inappropriate for CDT staff to take a group of consumers to a movie during program hours, staff could alternatively assist consumers in planning a recreational activity that occurs outside of the program hours. Similarly, while CDT programs should not offer GED preparation classes, they may assist consumers in identifying educational programs in the community and assist consumers in developing related skills and supports.
- As is currently the requirement, collateral visits include the provision of clinical support services of at least 30 minutes in duration. Group collateral visits include the provision of clinical support services of at least 60 minutes in duration. There is no minimum time period for the provision of crisis services. Under the new methodology, any collateral, group collateral or crisis visits that meet the regulatory minimums for service provision will be reimbursed as half-day visits. In these instances, the minimum two-hour program attendance requirement does not apply.
- Although not specifically addressed in the emergency regulations issued December 31, 2008, OMH plans to treat pre-admission visits in the same manner as crisis, collateral and group collateral visits. Specifically, the current regulations require that pre-admission visits are a minimum length of one hour. While we do not intend to modify that minimum requirement, the regulations will be revised in the near future to clarify that any pre-admission visits that meet the minimum duration of one hour may be billed as half-day visits.
- Tiers are determined by totaling the number of full-day and half-day regular visits, based on their hour equivalents. For example, five full-day visits represent the equivalent of 20 hours (5 visits x 4 hours) and five half-day visits represent the equivalent of 10 hours (5 visits x 2 hours). Crisis, collateral, group collateral, and pre-admission visits do not count toward the tier assignment. It should be noted that, for Article 31 CDTs, the new tiers represent the same number of full-days as were represented in the previous tier classification.
- Although CDT rates were reduced effective January 1, 2009, the revised billing methodology becomes effective on April 1, 2009. (The revised methodology is not retroactive to January 1.) The delay in applying the new methodology was intended to allow providers time to modify their billing systems.
- As with any significant program changes, modifications of this nature will require the submission of a Prior Approval Review (PAR) application. Any PAR applications submitted by CDT programs will be reviewed on a case-by-case basis. It should be noted, however, that the revised reimbursement methodology is being implemented in association with fee reductions, consistent with OMH's Financial Management Plan (FMP), which was developed in response to New York State's unprecedented fiscal crisis. Therefore, OMH's review of any CDT PAR application will need to be conducted within the context of the overall FMP. The configuration of any program, including any changes to volume, must be based on the clinical presentation of the population served.
- No, individuals may not attend multiple CDT programs. Individuals requiring a full-day session should be referred to a CDT program that offers full-day sessions.
- The frequency at which any consumer attends a CDT program should be based on individual clinical needs and consumer choice. It should be noted that any requests to reconfigure an existing CDT program will be reviewed in the context of OMH's Financial Management Plan, as described in the answer to Question # 14.