CHAPTER 1153. OUTPATIENT PSYCHIATRIC SERVICES

GENERAL PROVISIONS

Sec.


1153.1.    Policy.
1153.2.    Definitions.

COVERED AND NONCOVERED SERVICES


1153.11.    Types of services covered.
1153.12.    Outpatient services.
1153.14.    Noncovered services.

SCOPE OF BENEFITS


1153.21.    Scope of benefits for the categorically needy.
1153.22.    Scope of benefits for the medically needy.
1153.23.    Scope of benefits for State Blind Pension recipients.
1153.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1153.41.    Participation requirements.
1153.41a.    Medication prescription—statement of policy.
1153.42.    Ongoing responsibilities of providers.

PAYMENT FOR OUTPATIENT PSYCHIATRIC CLINIC AND OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION SERVICES


1153.51.    General payment policy.
1153.52.    Payment conditions for various services.
1153.53.    Limitations on payment.
1153.53a.    Requests for waiver of hourly limits.
1153.54.    Noncompensable services and items.

UTILIZATION REVIEW


1153.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1153.81.    Provider misutilization.

Source

   The provisions of this Chapter 1153 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope); 55 Pa. Code §  1101.95 (relating to conflicts between general and specific provisions); and 55 Pa. Code §  1221.2 (relating to definitions).

GENERAL PROVISIONS


§ 1153.1. Policy.

 The MA Program provides payment for specific medically necessary psychiatric outpatient clinic and psychiatric outpatient partial hospitalization services rendered to eligible recipients by psychiatric outpatient clinics and psychiatric outpatient partial hospitalization facilities enrolled as providers under the program. Payment for outpatient psychiatric services is subject to the provisions of this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to the MA Program payment policies) and the MA Program fee schedule.

Source

   The provisions of this §  1153.1 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (117398).

§ 1153.2. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Adult partial hospitalization program—A program licensed by the Department, Office of Mental Health, to provide partial hospitalization services to individuals 15 years of age or older.

   Children and youth partial hospitalization program—A program licensed by the Department Office of Mental Health, to provide partial hospitalization services to individuals 14 years of age or younger.

   Clinical staff—A psychiatrist or a mental health professional or mental health worker under the direct supervision of a psychiatrist.

   Collateral family psychotherapy—Psychotherapy provided to the family members of a clinic patient in the absence of that patient.

   Department—The Department of Human Services.

   Family—A person living alone or the following persons: spouses; parents and their unemancipated minor children and other unemancipated minor children who are related by blood or marriage; or other adults or emancipated minor children living in the household who are dependent upon the head of the household.

   Family psychotherapy—Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental disorder. Sessions shall be at least 1/2 hour in duration and shall be conducted by a clinical staff person.

   Group psychotherapy—Psychotherapy provided to no less than two and no more than ten persons with diagnosed mental disorders for a period of at least 1 hour. These sessions shall be conducted by a clinical staff person.

   Home visit—A visit made to an eligible recipient’s place of residence, other than a treatment institution or nursing home, for the purpose of observing the patient in the home setting or providing a compensable outpatient psychiatric service.

   Individual psychotherapy—Psychotherapy provided to one person with a diagnosed mental disorder for a minimum of 1/2 hour. These sessions shall be conducted by a clinical staff person.

   Inpatient—A patient who has been admitted to a treatment institution or an acute care hospital or psychiatric hospital on the recommendation of a physician and is receiving room, board and professional services in the facility on a continuous 24-hour-a-day basis.

   Intake—The first contact with a patient for initiation or renewal of services.

   Mental disorder—Conditions characterized as mental disorders by the International Classification of Diseases—ICD-9-CM—including mental retardation with associated psychiatric conditions (ICD-9-CM codes 317 to 319) and excluding drug/alcohol conditions (ICD-9-CM codes 291—292.9).

   Mental health professional—A person trained in a generally recognized clinical discipline including but not limited to psychiatry, social work, psychology or nursing, rehabilitation or activity therapies who has a graduate degree and clinical experience.

   Mental health worker—A person who does not have a graduate degree in a clinical discipline but who by training and experience has achieved recognition as a mental health worker, or a person with a graduate degree in a clinical discipline.

   Outpatient—A person who is not a resident of a treatment institution and who is receiving covered medical and psychiatric services at an approved or licensed outpatient psychiatric clinic or partial hospitalization facility which is not providing him with room and board and professional services on a continuous 24-hour-a-day basis.

   Psychiatric clinic clozapine monitoring and evaluation visit—A minimum 15-minute visit for the monitoring and evaluation of a patient’s physical and mental condition during the course of treatment with clozapine. The term includes only a visit provided to an eligible recipient receiving clozapine therapy, and only by a psychiatrist, physician, registered nurse (RN) or physician assistant.

   Psychiatric clinic medication visit—A minimum 15-minute visit only for administration of a drug and evaluation of a patient’s physical and mental condition during the course of prescribed medication. This visit is provided to an eligible recipient only by a psychiatrist, physician, registered nurse or licensed practical nurse who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing.

   Psychiatric evaluation—An initial mental status examination and evaluation of a patient provided only by a psychiatrist in a face-to-face interview with the patient. It shall include a comprehensive history and evaluation of pertinent diagnostic information necessary to arrive at a diagnosis and treatment plan, recommendations for treatment or further diagnostic studies or consultation. The history shall include individual, social, family, occupational, drug, medical and previous psychiatric diagnostic and treatment information.

   Psychiatric outpatient clinic provider—A facility approved by the Department, Office of Medical Assistance, and fully approved/licensed by the Department, Office of Mental Health, to provide specific medical, psychiatric and psychological services for the diagnosis and treatment of mental disorders. Treatment is provided to eligible Medical Assistance outpatient recipients who are not residents of a treatment institution or receiving similar treatment elsewhere.

   Psychiatric outpatient clinic services—Outpatient medical, psychiatric and psychological services listed in the MA Program Fee Schedule furnished to a mentally disordered outpatient while the person is not a resident of a treatment institution, provided by or under the supervision of a psychiatrist in a facility organized and operated to provide medical care to outpatients.

   Psychiatric outpatient partial hospitalization provider—A facility approved by the Department of Human Services, Office of Medical Assistance, to provide partial hospitalization services and fully approved/licensed by the Department, Office of Mental Health, to provide psychiatric, medical, psychological and psychosocial services as partial hospitalization for the diagnosis and treatment of mental disorders. Treatment is provided to eligible MA outpatient recipients who are not residents of a treatment institution or receiving similar treatment elsewhere.

   Psychiatric partial hospitalization—An active outpatient psychiatric day or evening treatment session including medical, psychiatric, psychological, and psychosocial treatment listed in the MA Program Fee Schedule. This service shall be provided to mentally disordered outpatients in a supervised, protective setting for a minimum of 3 hours and a maximum of 6 hours in a 24-hour period. The session shall be provided by a psychiatrist or by psychiatric partial hospitalization personnel under the supervision of a psychiatrist.

   Psychologist in preparation for licensure—A person who has completed the educational requirements for licensure and is accruing the required postdegree experience for licensing.

   Psychotherapy—The treatment, by psychological means, of the problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object of removing, modifying or retarding existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality growth and development.

   Supervision by a psychiatrist—The psychiatrist personally provides or orders, guides and oversees compensable medical, psychiatric and psychological services provided to recipients by psychiatric outpatient clinic or partial hospitalization personnel as specified in §  1153.52(a) (relating to payment conditions for various services).

   Treatment institution—A facility approved or licensed by the Department or its agents that provides full- or part-time psychiatric treatment services for resident patients with mental disorders—mental retardation residential facilities or community residential rehabilitation services are not considered to be mental health institutions.

Source

   The provisions of this §  1153.2 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended October 2, 1981, effective October 3, 1981, 11 Pa.B. 3387; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361. Immediately preceding text appears at serial pages (131000) to (131003).

Cross References

   This section cited in 55 Pa. Code §  1153.52 (relating to payment conditions for various services).

COVERED AND NONCOVERED SERVICES


§ 1153.11. Types of services covered.

 Medical Assistance Program coverage for outpatient psychiatric clinics and partial hospitalization facilities is limited to professional medical and psychiatric services for the diagnosis and treatment of mental disorders, including mental retardation, as specified in the MA Program Fee Schedule.

Source

   The provisions of this §  1153.11 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86830).

§ 1153.12. Outpatient services.

 The outpatient psychiatric clinic services specified in the MA Program Fee Schedule and the outpatient psychiatric partial hospitalization services specified in the MA Program Fee Schedule are covered only when provided by approved outpatient psychiatric clinics or psychiatric partial hospitalization facilities when ordered by a psychiatrist. Payment is subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1153.12 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86830).

§ 1153.14. Noncovered services.

 Payment will not be made for the following types of services regardless of where or to whom they are provided:

   (1)  A covered clinic or partial hospitalization service conducted over the telephone.

   (2)  Cancelled appointments.

   (3)  Covered services that have not been rendered.

   (4)  A MA covered service, including psychiatric clinic and partial hospitalization services, provided to inmates of State or county correctional institutions or committed residents of public institutions.

   (5)  Psychiatric outpatient clinic or partial hospitalization services to residents of treatment institutions, such as, persons who are also being provided with room or board or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program.

   (6)  Services delivered at locations other than approved psychiatric outpatient clinics or partial hospitalization facilities with the exception of home visits under the conditions specified in §  1153.52(d) (relating to payment conditions for various services).

   (7)  Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics.

   (8)  Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities.

   (9)  Psychiatric outpatient clinic services and psychiatric partial hospitalization provided on the same day to the same patient.

   (10)  Covered psychiatric outpatient clinic services and psychiatric partial hospitalization services, with the exception of family psychotherapy, provided to persons without a mental disorder or mental retardation diagnosis rendered by a psychiatrist in accordance with the International Classification of Diseases—ICD-9-CM, Chapter V, ‘‘Mental Disorders.’’

   (11)  Psychiatric outpatient clinic and psychiatric partial hospitalization services provided to patients with drug/alcohol abuse or dependence problems, such as alcohol dependence and nondependent abuse of drugs, alcohol psychoses, and drug psychoses, unless the patient has a primary diagnosis of a nondrug/alcohol abuse/dependence related mental disorder.

   (12)  Drugs and biologicals and supplies furnished to psychiatric clinic or psychiatric partial hospitalization patients during a visit to the clinic or facility. These are included in the clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided in the clinic are noncompensable.

   (13)  Services not specifically included in the MA Program Fee Schedule are noncompensable.

   (14)  Home visits not provided in accordance with the conditions specified in §  1153.52(d).

   (15)  Services provided beyond the 15th calendar day following intake, without the psychiatrist’s review and approval of the initial assessment and treatment plan.

   (16)  The hours that the client participates in an education program delivered in the same setting as a children and youth partial hospitalization program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the client is in direct contact with a clinical staff person.

   (17)  Group psychotherapy provided in the patient’s home.

   (18)  Psychiatric clinic and partial hospitalization services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.

Source

   The provisions of this §  1153.14 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (86830) to (86832).

SCOPE OF BENEFITS


§ 1153.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for the full range of covered psychiatric outpatient clinic and psychiatric partial hospitalization services in the MA Program Fee Schedule.

Source

   The provisions of this §  1153.21 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86832).

§ 1153.22. Scope of benefits for the medically needy.

 Medically needy recipients are eligible for the full range of covered psychiatric outpatient clinic and psychiatric partial hospitalization services in the MA Program Fee Schedule.

Source

   The provisions of this §  1153.22 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86832).

§ 1153.23. Scope of benefits for State Blind Pension recipients.

 State Blind Pension recipients are eligible for the full range of covered psychiatric outpatient clinic and psychiatric partial hospitalization services in the MA Program fee schedule.

Source

   The provisions of this §  1153.23 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (86832) to (86833).

§ 1153.24. Scope of benefits for General Assistance recipients.

 General Assistance recipients, age 21 to 65, whose MA benefits are funded solely by State funds, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See §  1101.31(e) (relating to scope).

Source

   The provisions of this §  1153.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION


§ 1153.41. Participation requirements.

 In addition to the participation requirements established in Chapter 1101 (relating to general provisions), outpatient psychiatric clinics and outpatient partial hospitalization facilities shall meet the following participation requirements:

   (1)  Have current full licensure/approval as a psychiatric outpatient clinic or partial hospitalization outpatient facility by the Department’s Office of Mental Health. To remain eligible for MA reimbursement, a clinic or partial hospitalization facility shall be fully licensed/approved at all times as a psychiatric outpatient clinic or partial hospitalization outpatient facility.

   (2)  Have medical personnel currently licensed, certified or registered in accordance with laws of the Commonwealth.

   (3)  Have a written patient referral plan that provides for inpatient hospital care and follow-up treatment.

   (4)  Post a current written fee schedule for billing third party and private payors.

   (5)  Appoint an administrator or director responsible for the internal operation of the clinic or partial hospitalization facility. Appoint a psychiatrist or psychiatrists responsible for the supervision and direction of services rendered to eligible recipients.

   (6)  Notify immediately the Department, Office of Medical Assistance, Bureau of Provider Relations, in writing, of a facility or clinic name, address, and service changes prior to the effective date of change. Failure to do so may result in payment interruption or termination of the provider agreement.

   (7)  Enter into a written provider agreement with the Department.

   (8)  Have each branch location or satellite of an approved clinic or partial hospitalization facility also licensed or approved by the Office of Mental Health as a psychiatric outpatient clinic site or psychiatric partial hospitalization facility, whichever is applicable, and approved by the Office of Medical Assistance before reimbursement can be made for services rendered at the branch or satellite. Approval of the parent organization does not constitute approval for any branches or satellites of the same organization.

   (9)  Be approved by the Department’s Office of Medical Assistance.

   (10)  Have medications prescribed by a licensed physician.

Source

   The provisions of this §  1153.41 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046. Immediately preceding text appears at serial pages (47826) and (47827).

§ 1153.41a. Medication prescription—statement of policy.

 Medications may be prescribed by a certified registered nurse practitioner in outpatient psychiatric clinics and outpatient partial hospitalization facilities as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners).

Source

   The provisions of this §  1153.41a adopted March 26, 2010, effective March 27, 2010, 40 Pa.B. 1644.

§ 1153.42. Ongoing responsibilities of providers.

 (a)  Responsibilities of providers. Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions). Outpatient psychiatric clinics and outpatient psychiatric partial hospitalization facilities shall also adhere to the additional requirements established in this section.

 (b)  Recordkeeping requirements. In addition to the requirements listed in §  1101.51(e) (relating to ongoing responsibilities of providers), the following items shall be included in medical records of MA patients receiving outpatient psychiatric clinic and outpatient psychiatric partial hospitalization services:

   (1)  The treatment plan shall include:

     (i)   The treatment plan goals.

     (ii)   Services to be provided to the patient in the clinic or partial hospitalization facility or through referral.

     (iii)   Persons to directly provide each service.

   (2)  As part of the progress notes, the frequency and duration of each service provided shall be included.

Source

   The provisions of this §  1153.42 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267.

PAYMENT FOR OUTPATIENT PSYCHIATRIC CLINIC
AND OUTPATIENT PSYCHIATRIC PARTIAL
HOSPITALIZATION SERVICES


§ 1153.51. General payment policy.

 Payment is made for medically necessary professional medical and psychiatric services provided by or under the supervision and direction of a psychiatrist in participating outpatient psychiatric clinics and outpatient psychiatric partial hospitalization facilities, subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule. Payment will not be made for a compensable psychiatric clinic or psychiatric partial hospitalization service if payment is available from another public agency or another insurance or health program.

Source

   The provisions of this §  1153.51 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86834).

§ 1153.52. Payment conditions for various services.

 (a)  The following conditions shall be met by outpatient psychiatric clinics and partial hospitalization programs, as applicable, to be eligible for payment:

   (1)  A psychiatrist shall be present in the psychiatric outpatient clinic and psychiatric outpatient partial hospitalization facility, as required by the Office of Mental Health approval/licensing regulations, to perform or supervise the performance of all covered services provided to MA patients.

   (2)  Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview with the patient. Additional interviews with other staff may be included as part of the examination but shall be included in the psychiatric evaluation fee. Separate billings for these additional interviews are not compensable.

   (3)  Psychotherapy—individual, family, collateral family or group—shall be provided only by a clinical staff person.

   (4)  Psychiatric partial hospitalization services shall be provided only by a clinical staff person.

   (5)  Diagnostic psychological and intellectual evaluations shall be administered and interpreted only by a licensed psychologist or by a psychologist in preparation for licensure under the direct supervision of a licensed psychologist.

   (6)  The psychiatric clinic medication visit shall be provided only by a psychiatrist, physician, registered nurse or licensed practical nurse who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing.

   (7)  Within 15 consecutive calendar days following intake, a mental health professional or mental health worker under the supervision of a mental health professional, shall examine and initially assess each patient in the clinic; determine the patient’s diagnosis and prepare an initial treatment plan; and date and sign the examination, diagnosis and treatment plan in the patient’s record. The treatment plan shall be developed, maintained and periodically reviewed in accordance with the following criteria:

     (i)   The psychiatrist shall verify each patient’s diagnosis and approve the treatment plan prior to the provision of any treatment beyond the 15th day following intake. This review and approval shall be dated and signed in the patient’s record.

     (ii)   The psychiatrist and mental health professional, or mental health worker under the supervision of a mental health professional, shall review and update each patient’s treatment plan at least every 120 days or 15 clinic visits, whichever is first, or, as may otherwise be required by law throughout the duration of treatment. Each review and update shall be dated, documented and signed in the patient’s record by the psychiatrist and mental health professional.

     (iii)   The treatment plan and updates shall be based upon the evaluation and diagnosis. Treatment shall be provided in accordance with the treatment plan and updates. Psychiatrists’ reviews and reevaluations of diagnoses, treatment plans and updates shall be done with the mental health professional or mental health worker under the supervision of a mental health professional, in the clinic and, whenever possible, with the patient.

   (8)  The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for a person receiving clozapine therapy.

 (b)  Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric outpatient partial hospitalization provided to eligible patients with mental disorders in approved psychiatric outpatient partial hospitalization facilities under the following conditions:

   (1)  Patients receiving partial hospitalization services shall meet the following criteria:

     (i)   Have a mental disorder diagnosis that has been verified by a psychiatrist.

     (ii)   Have a psychiatric condition requiring more intensive treatment than that provided by an outpatient clinic.

     (iii)   Have a psychiatric condition requiring provision of a supervised, protective setting for a prescribed time period to prevent institutionalization or ease the transition from inpatient care to more independent living.

   (2)  The following components shall be available in an approved psychiatric partial hospitalization facility and provided to the patient, if necessary, in accordance with the patient’s individualized treatment plan:

     (i)   Individual, group and family psychotherapy.

     (ii)   Health education—basic physical and mental health information; nutrition information and assistance in purchasing and preparing food, personal hygiene instruction; basic health care information, child care information and family planning information and referral; information on prescribed medications.

     (iii)   Instruction in basic care of the home or residence for daily living.

     (iv)   Instruction in basic personal financial management for daily living.

     (v)   Medication administration and evaluation provided only by a psychiatrist, physician, registered nurse or licensed practical nurse.

     (vi)   Guided social interaction supervised by psychiatric partial hospitalization personnel.

     (vii)   Crisis management provided by psychiatric partial hospitalization personnel.

     (viii)   Referral.

 (c)  Psychiatric outpatient clinic. Payment will only be made for psychiatric outpatient clinic services provided to eligible patients with mental disorders in approved psychiatric outpatient clinics under the following conditions:

   (1)  Psychiatric clinic medication visits shall be a minimum duration of 15 minutes. They shall be provided only for the purpose of administering medication, and for evaluating the physical and mental condition of the patient during the course of prescribed medication.

   (2)  Patients receiving psychiatric clinic services shall have a mental disorder diagnosis verified by a psychiatrist.

   (3)  Family psychotherapy is compensable only if one or more family members has a mental disorder diagnosis.

   (4)  Psychiatric clinic clozapine monitoring and evaluation visits shall be a minimum duration of 15 minutes. They shall be provided only for a person receiving clozaril and for monitoring and evaluating the patient’s white blood cell count to determine whether clozapine therapy should be continued or modified.

 (d)  Psychiatric clinic services provided in the home. Psychiatric clinic services delivered in the patient’s home are subject to the conditions and limitations established in the chapter. Home visits, as defined in §  1153.2 (relating to definitions), are compensable as outpatient psychiatric services listed in the MA Program Fee Schedule only if the physician’s documentation in the patient’s records and progress notes fully substantiates that one of the following conditions exists:

   (1)  The client’s disability requires specialized transportation which is not generally available.

   (2)  The client has a behavior disorder which disrupts the clinic environment.

   (3)  The client has a diagnosis of agoraphobia.

 (e)  Observation of the client in the home environment. Observation of the client in the home environment is considered to be an individual psychotherapy service and is compensable only when:

   (1)  The client is currently in therapy.

   (2)  Observation of the client in his home setting is a necessary component of the clients’ psychotherapeutic regimen.

Source

   The provisions of this §  1153.52 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361. Immediately preceding text appears at serial pages (131009) to (131012).

Cross References

   This section cited in 55 Pa. Code §  1153.2 (relating to definitions); and 55 Pa. Code §  1153.14 (relating to noncovered services).

§ 1153.53. Limitations on payment.

 (a)  Payment is subject to the following limitations:

   (1)  For recipients 21 years of age or older, 180 three-hour sessions, 540 total hours, of psychiatric partial hospitalization in a fiscal year per recipient, except for State Blind Pension recipients, for whom payment is limited to 240 3-hour sessions, 720 total hours, of psychiatric partial hospitalization in a consecutive 365-day period per recipient.

   (2)  At least 3 hours but no more than 6 hours of psychiatric partial hospitalization per 24-hour period.

   (3)  Two outpatient psychiatric evaluations in psychiatric clinics per patient per year.

   (4)  For recipients 21 years of age or older, a total of 5 hours or 10 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period, except for State Blind Pension recipients, for whom payment is limited to a total of 7 hours or 14 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period. This period begins on the first day that an eligible recipient receives an outpatient psychiatric clinic service listed in the MA Program Fee Schedule. Psychotherapy includes the total of individual, group, family, collateral family psychotherapy services and home visits provided per eligible recipient per 30-consecutive day period.

   (5)  Three psychiatric clinic medication visits per patient per 30-consecutive days in psychiatric outpatient clinics.

   (6)  One outpatient comprehensive diagnostic psychological evaluation or no more than $80 worth of individual psychological or intellectual evaluations in psychiatric clinics per patient per 365 consecutive days.

   (7)  The partial hospitalization fees listed in the MA Program Fee Schedule include payment for all services rendered to the patient during a psychiatric partial hospitalization session. Separate billings for individual services are not compensable.

   (8)  Partial hospitalization facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the client receiving treatment.

   (9)  Partial hospitalization facilities licensed as children and youth programs will be reimbursed at the child rate only when the client receiving treatment is 14 years of age or younger.

   (10)  Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.

   (11)  Psychiatric clinic clozapine monitoring and evaluation visits are limited to five visits per patient per calendar month.

   (12)  Any combination of psychiatric clinic medication visits and psychiatric clinic clozapine monitoring and evaluation visits is limited to five per patient per calendar month.

 (b)  The Department is authorized to grant an exception to the limits specified in subsection (a)(1) and (4) as described in §  1101.31(f) (relating to scope).

Authority

   The provisions of this §  1153.53 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1153.53 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective Janaury 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial pages (278537) to (278538).

§ 1153.53a. Requests for waiver of hourly limits.

 (a)  Clients who are 20 years of age or younger and who are diagnosed as having one of the medical conditions listed in this section, or conditions of equal severity, may request a waiver from the general limitation on the number of hours of covered services. The medical conditions are:

   (1)  Infantile autism.

   (2)  Atypical childhood psychosis.

   (3)  Borderline psychosis of childhood.

   (4)  Schizophrenia.

   (5)  Schizophrenic syndrome of childhood.

   (6)  Impulse control disorder.

   (7)  Early deprivation syndrome.

   (8)  Unsocialized aggressive reaction.

   (9)  Hyperkinetic conduct disorder.

   (10)  Over anxious disorder.

   (11)  Anorexia nervosa.

   (12)  Neurotic depression—with suicidal ideation.

 (b)  The request for a waiver shall be accompanied by supporting medical documentation and a second physician’s certification as to the medical necessity of psychotherapy beyond the general limitation.

 (c)  The request for a waiver is reviewed by the Office of Mental Health, Bureau of Community Programs, and acted upon within 30 days of receipt. Failure to act within 30 days constitutes approval of the waiver.

 (d)  Waivers are granted for periods of up to 6 months. Requests for additional waivers shall be submitted 30 days prior to the expiration of an existing waiver and are reviewed under the same conditions as specified above.

 (e)  Requests for waivers must be submitted to: Department of Human Services, Office of Medical Assistance, Room 515 Health and Welfare Building, Harrisburg, Pennsylvania 17120.

 (f)  A denial of a waiver request may be appealed under the same terms and conditions as any denial of services. See Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). Notice of a decision of waiver request will be mailed to the MA recipient and to the provider of services.

Source

   The provisions of this §  1153.53a adopted November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046.

§ 1153.54. Noncompensable services and items.

 Payment will not be made for items and services not listed as compensable in the MA Program Fee Schedule.

Source

   The provisions of this §  1153.54 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective Janaury 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86838).

UTILIZATION REVIEW


§ 1153.71. Scope of claims review procedures.

 Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1153.71 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267.

ADMINISTRATIVE SANCTIONS


§ 1153.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of medical practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1153.81 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267.

APPENDIX A. [Reserved]



Source

   The provisions of this Appendix A adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (67880).

APPENDIX B. [Reserved]



Source

   The provisions of this Appendix B adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended October 2, 1981, effective October 3, 1981, 11 Pa.B. 3387; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (67881).



No part of the information on this site may be reproduced for profit or sold for profit.

This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.