14 CRR-NY 599.14NY-CRR
14 CRR-NY 599.14
14 CRR-NY 599.14
599.14 Medical assistance billing standards.
(a) Medicaid claims for individuals who have been admitted to a clinic treatment program shall include, at a minimum, the Medicaid identification number of the recipient, 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 recipient, no more than one of which may be a collateral procedure. For children, claims may be reimbursed for up to three pre-admission visits. Such claims shall include, at a minimum, the Medicaid identification number of the recipient, 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. For pre-admission visits at least the code for diagnosis-deferred must be entered on the claim.
(c) Medicaid claims may be submitted for no more than three services per day for any individual, not including crisis intervention or complex care management services. 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. Medicaid claims may be submitted for no more than one off-site service per child, per day, excluding crisis intervention services.
(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 during an episode of service. Additional initial assessment procedures shall not be eligible for Medicaid reimbursement if less than 365 days have transpired since the most recent Medicaid reimbursed visit to the clinic.
(i) Initial assessments shall include performance or consideration, as applicable, of the health screening.
(a) Initial assessment interviews provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19. The location and reason for delivering the service off-site must be documented in the treatment plan.
(b) The clinic must document a minimum of 45 minutes face-to-face contact with the recipient. 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.
(c) Clinics 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 recipient during the time the initial assessment is being conducted by another licensed practitioner.
(ii) A psychiatric assessment may be provided to either an individual being assessed for admission to the clinic, 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 psychiatrist, nurse practitioner in psychiatry, or physician assistant with specialized training approved by the office to an individual who has been admitted to the clinic, 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 recipient and the 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 recipient and the psychiatrist or nurse practitioner in psychiatry shall be billed as an extended psychiatric assessment.
(d) A psychiatric assessment provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19.
(2) Psychiatric consultation.
(i) Psychiatric consultation may be provided by a psychiatrist or nurse practitioner in psychiatry to a referring physician for the purposes of assisting in the diagnosis, integration of treatment, or assistance in ensuring continuity of care, for a patient of the referring physician.
(ii) Psychiatric consultation services must be face-to-face with the recipient, or through video tele-psychiatry, where available.
(3) Crisis intervention.
(i) The clinic 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 clinic is located, or by the office for county-operated clinics.
(ii) Crisis intervention services consist of three billable levels of service.
(a) Crisis intervention - brief. Brief crisis intervention services shall be done face-to-face or by telephone. 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. For all recipients, off-site crisis intervention – brief services provided on or after October 1, 2010 shall be reimbursable on a federally-non-participating basis.
(b) Crisis intervention – 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. A peer advocate, family advisor, or non-licensed staff may substitute for one clinician. Clinics may be reimbursed for crisis services provided to individuals who have not engaged in services for a period of up to two years.
(c) Crisis intervention – 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. A peer advocate, family advisor, or non-licensed staff may substitute for one clinician. Clinics may be reimbursed for crisis 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 face-to-face contact between a clinician and the recipient. Such services provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19. 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 consumer education, as necessary.
If the injectable psychotropic medication administration with monitoring and education service is provided to a recipient by a physician or nurse practitioner in psychiatry, it shall not be claimed in addition to an evaluation and management service (including psychiatric assessment and psychotropic medication treatment) received by that recipient on the same day. In this case, the clinic 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 physician or nurse practitioner in psychiatry and the recipient. Such services provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19.
(6) Psychotherapy services. Psychotherapy services consist of the following levels of billable service.
(i) Psychotherapy services - individual shall be reimbursed as follows:
(a) brief individual psychotherapy service:
(1) service provided face-to-face with the recipient with a documented duration of 30 minutes shall receive full reimbursement; or
(2) effective January 1, 2015, service provided face-to-face with the recipient will be documented duration of 20 minutes shall receive a 30 percent reduction in reimbursement.
(b) extended individual psychotherapy service:
(1) service provided face-to-face with the recipient requires a documented duration of 45 minutes; or
(2) effective January 1, 2015, service provided face-to-face with the recipient requires a documented duration of 30 minutes (with or without a collateral), with the remaining 15 minutes spent with the collateral (with or without the recipient);
(3) 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.
(c) Brief or extended psychotherapy services provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19.
(ii) Psychotherapy – family/collateral with the recipient requires documented cumulative, continuous face-to-face service with the recipient and the collateral of a minimum duration of 60 minutes, during which time the recipient shall be present for at least the majority of the time. Such services provided on or after October 1, 2010, to a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19.
(iii) Psychotherapy – family/collateral without the recipient requires documented face-to-face service with the collateral of a minimum duration of 30 minutes. For this service, the recipient may also be present for some or all of the time. Such services provided on or after October 1, 2010, on behalf of a child off-site shall be reimbursable on a federally-non-participating basis and only for children up to age 19.
(iv) Psychotherapy – multi-recipient 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 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.
(v) Psychotherapy – multi-family/collateral group requires documented face-to-face service with a minimum of two multi-family/collateral units and a maximum of eight multi-family/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.
(7) Developmental testing. Medical assistance may reimburse for this service solely for individuals admitted to the clinic. Developmental testing services must be face-to-face with the recipient.
(8) Psychological testing. Medical assistance may reimburse for this service solely for individuals admitted to the clinic. Psychological testing services must be face-to-face with the recipient.
(9) Effective October 1, 2014, complex care management must be provided within 14-calendar days following a face-to-face psychotherapy, psychotropic medication treatment, or crisis intervention 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 clinic 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.
(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 - Per 15 minutes | x | x | |
| Crisis Intervention Service - Per Hour | x | x | |
| Crisis Intervention Service - Per Diem | x | x | |
| Developmental and Psychological Testing | x | x | |
| Injectable Psychotropic Medication Administration with Monitoring and Education - Minimum of 15 Minutes | x | x | |
| Psychotropic Medication Treatment - Minimum of 15 Minutes | x | x | |
| Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development | x | x | x |
| Psychiatric Assessment - Minimum of 30 Minutes | x | x | |
| Psychiatric Assessment - Minimum of 45 Minutes | x | x | |
| Individual Psychotherapy - Minimum of 30 Minutes | x | x | x |
| Individual Psychotherapy - Minimum of 45 Minutes | x | x | x |
| Group and Multifamily/Collateral Group Psychotherapy - Minimum of 60 Minutes | x | x | x |
| Family Therapy/Collateral w/o patient - Minimum of 30 minutes | x | x | x |
| Family Therapy/Collateral with patient - Minimum of 60 minutes | x | x | x |
(f) A clinic may not be reimbursed for services provided to an individual currently enrolled in another licensed mental health outpatient program for which Medicaid reimbursement is being made, except as provided in this subdivision.
(1) Reimbursement shall be made for up to three pre-admission assessment visits when a recipient is in transition from another outpatient program, including another clinic, to the clinic. After completion of the three initial assessment visits, a clinic 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 recipient has been discharged from the other outpatient program.
(2) Reimbursement shall be made for a recipient currently admitted to a continuing day treatment program in accordance with Part 587 of this Title when such recipient shall also be admitted to a clinic treatment 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 recipient.
(3) Reimbursement shall be made for no more than five clinic visits per month for a recipient concurrently admitted to an intensive psychiatric rehabilitation treatment program.
(4) Reimbursement shall not be made for services rendered by a clinic to residents of a residential health care facility. Reimbursement shall be made to the clinic 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 clinics 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.
(2) Specialty clinics providing procedures to children with a serious emotional disturbance enrolled in Medicaid managed care may be paid Medicaid fee-for-service reimbursement for those procedures.
14 CRR-NY 599.14
Current through August 15, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: The "Current through" date indicated immediately above is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Administrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of NYS Rules.