CLINIC TREATMENT PROGRAMS
14 NYCRR Part 599
Adoption

14 NYCRR Part 599

1.  Part 599 of Title 14 NYCRR is amended to read as follows:

PART 599
CLINIC TREATMENT PROGRAMS
(Statutory Authority:  Mental Hygiene Law §§7.09, 31.02, 31.04, 31.06, 31.07, 31.09, 31.11, 31.13, 31.19, 41.13, 43.01, 43.02, Article 33 and Article 41;
Social Services Law §§364, 364-a, 364-j, 365–m)

Sec.
599.1	Background and intent.
599.2	Legal base.
599.3	Applicability.
599.4	Definitions.
599.5	Certification.
599.6	Organization and administration.
599.7	Rights of recipients.
599.8	Clinic services
599.9	Staffing.
599.10	Treatment planning.
599.11	Case records.
599.12	Premises.
599.13	Medical assistance clinic reimbursement system.
599.14	Medical assistance billing standards.
599.15	Indigent care.
599.16	Behavioral health organizations.

2.  Subdivision (e) of section 599.1 of Title 14 NYCRR is amended to read as follows:

(e) It is the intent of the Office of Mental Health that the goals described in this section be achieved through the establishment and operation of programs that [provide outreach to] address the symptoms and adverse effects of mental illness at their earliest stages, to avoid mental health crises where possible, and to respond in a timely and effective manner to such crises when they occur.  It is the intent of the Office to establish the clinic treatment program as a clinical home for the individual being served that provides a person–centered, recovery oriented and individualized approach to care.  Providers should utilize high quality and evidence–based practices and other practices which are supported by scientific research or generally accepted clinical practice guidelines to maximize individuals’ abilities; to minimize the symptoms, adverse effects and consequences of mental illness; to maintain and promote the individuals’ integration into the community; to support family integrity; and to provide ongoing support to service recipients and their relevant collaterals. 

3.  A new subdivision (n) of Section 599.2 of Title 14 NYCRR is added to read as follows:

(n)  Section 365–m of the Social Services Law authorizes the Commissioner of the Office of Mental Health and the Commissioner of the Office of Alcoholism and Substance Abuse Services, in consultation with the Department of Health, to contract with regional behavioral health organizations  to provide administrative and management services for the provision of behavioral health services.

4.  Subdivision (d) of Section 599.3 of Title 14 NYCRR is repealed and subdivision (e) is re–lettered as (d) as follows:

(d) [Medicaid reimbursement of outreach services and off–site services is contingent upon Federal approval.
 
(e)] Programs which provide medical services, other than health monitoring and health screening, that comprise more than five percent of total annual visits shall also be licensed by the Department of Health.

5.  Section 599.4 of Title 14 NYCRR is amended to read as follows:

§ 599.4  Definitions.  For purposes of this Part:

(a)  After hours means before 8 a.m., 6 p.m. or later, or during weekends.

(b) Ambulatory Patient Groups (APGs) means a defined group of outpatient procedures, encounters or ancillary services grouped for payment purposes.  The groupings are based on the intensity of the services provided and the medical procedures performed.   

(c) Base rate means the numeric value that shall be multiplied by the weight for a given service to determine the Medicaid fee for a service.

(d)  Behavioral Health Organization or BHO  means an entity selected by the Commissioner of the Office of Mental Health and the Commissioner of the Office of Alcoholism and Substance Abuse Services pursuant to Section 365–m of the New York State Social Services Law to provide administrative and management services for the purposes of conducting concurrent review of Behavioral Health admissions to inpatient treatment settings, assisting in the coordination of Behavioral Health Services, and facilitating the integration of such services with physical health care. 

(e) Clinic treatment program means a program licensed as a clinic treatment program under Article 31 of the Mental Hygiene Law.

[(e)](f) Clinical services contract means a written agreement between the governing authority of an existing or proposed provider of services and another organization separate from the provider of services for the purpose of obtaining some of the clinical services or some of the clinical staff necessary to operate the program in compliance with requirements for an operating certificate.

[(f)](g) Clinical staff means staff members who provide services directly to recipients, including licensed staff, non–licensed staff, and student interns.

[(g)](h) Clinician means a person who is a member of the professional staff.

[(h)](i) Collateral means a person who is a member of the recipient’s family or household, or other individual who regularly interacts with the recipient and is directly affected by or has the capability of affecting his or her condition, and is identified in the treatment plan as having a role in treatment and/or is 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.

[(i)](j) Commissioner means the Commissioner of the New York State Office of Mental Health.

[(j)](k) Community education means activities designed to increase community awareness of the manifestations of mental illness and emotional disturbance and the benefits of early identification and treatment.

[(k)](l) Complex care management means an ancillary service to psychotherapy or crisis intervention services.  It is provided by a clinician in person or by telephone, with or without the client.  It is a clinical level service which is required as a follow up to psychotherapy or crisis service for the purpose of preventing a change in community status or as a response to complex conditions.

(m) Concurrent Review means the review of the clinical necessity for continued inpatient Behavioral Health Services, resulting in a non–binding recommendation regarding the need for such continued inpatient services.

[(l)](n) Crisis intervention means activities, including medication and verbal therapy, designed to address acute distress and associated behaviors when the individual’s condition requires immediate attention. 

[(m)](o) Current Procedural Terminology (CPT) means codes used in a coding system for health care procedures as defined in the publication Current Procedural Terminology which is published by the American Medical Association.

[(n)](p) Designated mental illness means a disruption of normal cognitive, emotional, or behavioral functioning, which can be classified and diagnosed using the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), other than:

(1)	alcohol or drug disorders,
(2)	developmental disabilities,
(3)	organic brain syndrome or
(4)	social conditions (V–Codes).  V–Code 61–20 Parent–Child (or comparable diagnosis in any subsequent editions of the DSM) is included for children.

[(o)](q) Developmental testing means the administration, interpretation, and reporting of screening and assessment instruments for children or adolescents to assist in the determination of the individual’s developmental level for the purpose of facilitating the mental health diagnosis and treatment planning processes.

[(p)](r)  Diagnostic and treatment center, for the purposes of this Part, means an outpatient program licensed as a diagnostic and treatment center pursuant to article 28 of the Public Health Law which provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits.  A program providing fewer than 2,000 total visits annually shall not be [considered a diagnostic and treatment center] required to be licensed by the Office.

[(q)](s) Director of Community Services means the chief executive officer of the Local Governmental Unit.

[(r)](t) Episode of service means a series of services provided during a period of admission.  An episode of service terminates upon completion of the treatment objectives or cessation of services.

[(s)](u) Evidence–based treatment means an intervention for which there is consistent scientific evidence demonstrating improved recipient outcomes.

[(t)](v) Family advisor means an individual who has experience, credentials, or training recognized by the Office and is or has been the parent or primary caregiver of a child with emotional, behavioral or mental health issues.

[(u)](w) Health monitoring means the continued measuring of specific health indicators associated with increased risk of medical illness and early death.  For adults, these indicators include, but are not limited to, blood pressure, body mass index (BMI), substance use, and smoking [status] cessation.  For children and adolescents, these indicators include, but are not limited to, BMI percentile, activity/exercise level, substance use, and smoking [status] cessation. 

[(v)](x) Health physical means the physical evaluation of an individual, including an age and gender appropriate history, examination, and the ordering of laboratory/diagnostic procedures, as appropriate.

[(w)](y) Health screening means the initial gathering and assessing of information concerning the recipient’s medical history and current physical health status (including physical examination and determination of substance use) for purposes of informing an assessment and determination of its potential impact on a recipient’s mental health diagnosis and treatment, and the need for additional health services or referral. 

[(x)](z) Healthcare common procedure coding system (HCPCS codes) means a comprehensive, standardized coding and classification system for health services and products.

[(y)](aa) Homebound individuals means people who have been determined by a licensed clinician to have a physical and/or mental illness that prevents them from leaving their residence to access mental health services or for whom a physician determines that leaving the residence to access mental health services would be detrimental to their  health or mental health.

[(z)](ab)  Hospital–based clinic means [an outpatient program] a mental health clinic which is operated by a psychiatric hospital, or is located in a general hospital and is licensed under Article 28 of the Public Health Law and Article 31 of the Mental Hygiene Law, or is licensed solely under Article 28 of the Public Health Law [which is located in a general hospital] and provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits.  A [program providing] clinic licensed solely under Article 28 which provides fewer than 2,000 total visits annually shall not be [considered a hospital–based clinic] required to be licensed by the Office.

[(aa)](ac) Initial assessment means a face–to–face interaction between a clinician and recipient and/or collaterals to determine the appropriateness of the recipient for admission to a clinic, the appropriate mental health diagnosis, and the development of a treatment plan for such recipient.

 [(ab)](ad) Injectable psychotropic medication administration means the process of preparing[,] and administering[, and managing] the injection of intramuscular psychotropic medications.  [It includes consumer education related to the use of the medication, as necessary.]

(ae) Injectable psychotropic medication administration with monitoring and education means the process of preparing, administering, managing and monitoring the injection of intramuscular psychotropic medications.  It includes consumer education related to the use of the medication, as necessary. 

[(ac)](af) Limited permit means that the New York State Education Department has determined that permit holders have met all requirements for licensure except those relating to the professional licensing final examination, and that pending licensure limited permit holders are functioning under proper supervision as outlined in the New York State Education Department law governing each of the professions.

[(ad)](ag) Linkage with primary care means activities designed to promote coordination, continuity and efficiency of mental health services and primary care services received by the recipient.

[(ae)](ah) Local governmental unit (LGU) means the unit of local government authorized in accordance with Article 41 of the Mental Hygiene Law to provide and plan for local or unified services.

[(af)](ai) Mental health screening for children means a broad–based approach to identify children and adolescents with emotional disturbances in order to allow for intervention at the earliest possible opportunity.

 [(ag)](aj) Modifiers means payment adjustments made to Medicaid fees for specific reasons such as billing for [off–site services (within established limits),] services in languages other than English[,] and services delivered after hours.

[(ah)](ak) Non–licensed staff means individuals 18 years of age or older who do not possess a license issued by the New York State Education Department in one of the clinic professional staff categories listed in this Part and who may not provide therapeutic mental health services, except as may be authorized in section 599.9 of this Part.  Non–licensed staff includes employees who have a life experience related to mental illness or have education and training in human services.

[(ai)](al) Office means the New York State Office of Mental Health.
 
[(aj) Outreach means face–to–face services with an individual, or, in the case of a child, the child and/or family member(s) for the purpose of beginning or enhancing the engagement process, or reengaging with individuals who are reluctant to participate in services, or to promote early intervention to prevent a psychiatric crisis.] 

[(ak)](am) Peer advocate means an individual with personal experience as a mental health recipient, who has training, credentials or experience recognized by the Office.

[(al)](an)  Peer group [mean] means a grouping of providers sharing similar features such as geography or auspice.

[(am)](ao) Physician fee schedule means a payment schedule established by the Department of Health which is used to enhance the payment for specific services included in this Part.

[(an)](ap) Preadmission status means the status of an individual who is being evaluated to determine whether he or she is appropriate for admission to the clinic.

[(ao)](aq) Preadmission visit means visits provided prior to admission to clinic services.

[(ap)](ar) Primary clinician is a member of the professional staff responsible for the development and implementation of the treatment plan.

[(aq)](as)Professional staff means practitioners possessing a license or a permit from the New York State Education Department who are qualified by credentials, training, and experience to provide direct services related to the treatment of mental illness and shall include the following:

(1)	Creative arts therapist is an individual who is currently licensed as a creative arts therapist by the New York State Education Department or possesses a creative arts therapist permit from the New York State Education Department.
(2)	Licensed practical nurse is an individual who is currently licensed as a licensed practical nurse by the New York State Education Department or possesses a licensed practical nurse permit from the New York State Education Department.
(3)	Licensed psychoanalyst is an individual who is currently licensed as a psychoanalyst by the New York State Education Department or possesses a permit from the New York State Education Department.
(4)	Licensed psychologist is an individual who is currently licensed as a psychologist by the New York State Education Department or possesses a permit from the New York State Education Department and who possesses a doctoral degree in psychology, or an individual who has obtained at least a master's degree in psychology who works in a federal, state, county or municipally operated clinic. Such master’s degree level psychologists may use the title “psychologist,” may be considered professional staff, but may not be assigned supervisory responsibility.
(5)	Marriage and family therapist is an individual who is currently licensed as a marriage and family therapist by the New York State Education Department or possesses a permit from the New York State Education Department.
(6)	Mental health counselor is an individual who is currently licensed as a mental health counselor by the New York State Education Department or possesses a permit from the New York State Education Department.
(7)	Nurse practitioner is an individual who is currently certified as a nurse practitioner by the New York State Education Department or possesses a permit from the New York State Education Department.
(8)	Nurse practitioner in psychiatry is an individual who is currently certified as a nurse practitioner with an approved specialty area of psychiatry (NPP) by the New York State Education Department or possesses a permit from the New York State Education Department.
(9)	Physician is an individual who is currently licensed as a physician by the New York State Education Department or possesses a permit from the New York State Education Department.
(10)	Physician assistant is an individual who is currently registered as a physician assistant by the New York State Education Department or possesses a permit from the New York State Education Department.
(11)	Psychiatrist is an individual who is currently licensed to practice medicine in New York State, who (i) is a diplomate of the American Board of Psychiatry and Neurology or is eligible to be certified by that Board, or (ii) is certified by the American Osteopathic Board of Neurology and Psychiatry or is eligible to be certified by that Board.
(12)	Registered professional nurse is an individual who is currently licensed as a registered professional nurse by the New York State Education Department or possesses a permit from the New York State Education Department.
(13)	Social worker is an individual who is either currently licensed as a licensed master social worker or as a licensed clinical social worker (LCSW) by the New York State Education Department, or possesses a permit from the New York State Education Department to practice and use the title of either licensed master social worker or licensed clinical social worker.

[(ar)](at) Psychiatric assessment means an interview with an adult or child or his or her family member or other collateral, performed by a psychiatrist or nurse practitioner in psychiatry, or physician assistant with specialized training approved by the Office.  An assessment may occur at any time during the course of treatment, for the purposes of diagnosis, treatment planning, medication therapy, and/or consideration of general health issues.  A psychiatric assessment may [also] include [on–site psychiatric consultation which includes an evaluation, report or interaction between a psychiatrist or nurse practitioner in psychiatry or physician assistant with specialized training approved by the Office and a referring physician for the purposes of diagnosis, integration of treatment and continuity of care] psychotherapy, as appropriate.

[(as)](au) Psychiatric consultation means a face–to–face evaluation, which may be in the form of video tele–psychiatry, of a consumer by a psychiatrist or nurse practitioner in psychiatry, including the preparation, evaluation, report or interaction between the psychiatrist or nurse practitioner in psychiatry and another referring physician for the purposes of diagnosis, integration of treatment and continuity of care.

[(at)](av) Psychological testing means a psychological evaluation using standard assessment methods and instruments to assist in mental health assessment and the treatment planning processes.

[(au)](aw) Psychotherapy means therapeutic communication and interaction for the purpose of alleviating symptoms or dysfunction associated with an individual’s diagnosed mental illness or emotional disturbance, reversing or changing maladaptive patterns of behavior, encouraging personal growth and development, and supporting the individual’s capacity to achieve age–appropriate developmental milestones.

[(av)](ax) Psychotropic medication treatment means monitoring and evaluating target symptom response, ordering and reviewing diagnostic studies, writing prescriptions and consumer education as appropriate.

[(aw)](ay) Quality improvement means a systematic and ongoing process for measuring and assessing the performance of clinic services and for conducting initiatives and taking action to improve safety, effectiveness, timeliness, person centeredness or other aspects of services.

[(ax)](az) Satellite means a physically separate adjunct site to a certified clinic treatment program, which provides either a full or partial array of outpatient services on a regularly and routinely scheduled basis (full or part time). 

[(ay)](ba) Serious emotional disturbance means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) and has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis. The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas:

(1)	ability to care for self (e.g., personal hygiene; obtaining and eating food; dressing; avoiding injuries); or
(2)	family life (e.g., capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
(3)	social relationships (e.g., establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
(4)	self–direction/self–control (e.g., ability to sustain focused attention for a long enough period of time to permit completion of age–appropriate tasks; behavioral self–control; appropriate judgment and value systems; decision–making ability); or
(5)	ability to learn (e.g., school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

[(az)](bb) Specialty clinic means a clinic designated by the Commissioner as specializing in the provision of services to children who have a designated mental illness diagnosis and an impairment in functioning due to serious emotional disturbance.

[(ba)](bc) Supplemental payment means payments in addition to the service fee amount. 

[(bb)](bd) Treatment planning is an ongoing process of assessing the mental health status and needs of a recipient, establishing his or her treatment and rehabilitative goals and determining what services may be provided by the clinic to assist the individual in accomplishing these goals.

[(bc)](be)Visit means an interaction consisting of one or more procedures occurring between a recipient and/or collateral and the clinic staff on a given day.

[(bd)](bf) Weight means a numeric value that reflects the relative expected average resource utilization for each service as compared to the expected average resource utilization for all other services.

6.  Subdivision (l) of Section 599.6 of Title 14 NYCRR is amended to read as follows:

(l) There shall be a written utilization review procedure to ensure that all recipients are receiving appropriate services and are being served at an appropriate level of care.  Such policies and procedures shall include provisions ensuring that utilization review is performed, at a minimum, on a random 25 percent sample of open cases, and shall be performed only by professional staff trained to do such reviews, or by staff who are otherwise qualified by virtue of their civil service standing, and shall ensure to the maximum extent possible that the designated utilization review authority functions independently of the clinical staff that is treating the recipient under review.Such utilization review procedure shall provide for:

(1)	a review of the appropriateness of admission to a clinic treatment program; and
(2)	a review of the need for continued treatment in a clinic treatment program within seven months after admission and every six months thereafter unless the recipient is:

(i)	discharged out of the program and subsequently readmitted, wherein the cycle begins again; or
(ii)	receiving medication therapy and medication education services only, wherein the need for continued treatment shall be reviewed every 12 months thereafter.

[(3)	a determination by the treating clinician of the need for continued clinic treatment service beyond 40 visits per benefit year for adults to be documented in the case record no later than at the 40th visit during a benefit year.

(i)	Such determination shall include an estimate of the number of visits beyond 40 required for the recipient within the remaining benefit year.
(ii)	The need for continued clinic treatment service beyond this estimated number of visits shall be determined at or prior to the provision of the estimated number of visits during the benefit year. The need for any additional revised estimates shall be determined accordingly.

(4)

a determination by the treating clinician of the need for continued clinic treatment services beyond 40 visits per benefit year for children with a diagnosis of emotional disturbance in clinic treatment programs to be documented in the case record no later than at the 40th visit during a benefit year.

(i)	Such determination shall include an estimate of the number of visits beyond 40 required for the recipient within the remaining benefit year.
(ii)	The need for continued clinic treatment service beyond this estimated number of visits shall be determined at or prior to the provision of the estimated number of visits during the benefit year. The need of any additional revised estimates shall be determined accordingly.]

7.  Subdivisions (b) and (c) of Section 599.8 of Title 14 NYCRR are amended to read as follows:

(b)  Clinic treatment programs shall offer each of the following services, to be provided consistent with recipients’ conditions and needs:

(1)	[Outreach;
(2)]	Initial assessment (including health screening).  The health screening documentation may be provided by the recipient or obtained from other sources such as the recipient’s primary care physician, where appropriate;
[(3)](2)	Psychiatric assessment;
[(4)](3)	Crisis intervention.  The clinic shall have 24 hour a day/7 day per week availability of crisis intervention services.  After hours coverage shall include, at a minimum, the ability to provide brief crisis intervention services and shall be provided pursuant to a plan approved by the local governmental unit or the Office.  Such services shall be provided either directly or pursuant to a Clinical Services Contract. Such contract shall include, at a minimum, provisions assuring that, in the event of a crisis, the nature of the crisis and any measures taken to address such crisis are communicated to the primary clinician or other designated clinician involved in the individual’s treatment at the clinic, or the individual’s primary care or mental health care provider, if known, on the next business day.  At the request of the local governmental unit, State–operated clinics shall consult with the local governmental unit or units in their service area in the development of such clinic’s crisis response plan;
[(5)](4)	Injectable psychotropic medication administration (for clinics serving adults);
(5)	Injectable psychotropic medication administration with monitoring and education (for clinics serving adults);
(6)	Psychotropic medication treatment;
(7)	Psychotherapy services. Such services shall promote community integration and encompass interventions to facilitate readiness for and engagement of the client and family in wellness self management, schools, and employment;
(8)	Family/Collateral psychotherapy;
(9)	Group psychotherapy; and
(10)	Complex Care Management.

(c)  Clinics may offer the following optional services:

(1)	Developmental testing;
(2)	Psychological testing;
(3)	Health physicals;
(4)	Health monitoring;
(5)	Psychiatric consultation; or
(6)	Injectable psychotropic medication administration (for clinics serving only children)[.]; and
(7)	Injectable psychotropic medication administration with monitoring and education (for clinics serving only children).

8.  Subdivisions (b) and (c) of Section 599.9 of Title 14 NYCRR are amended to read as follows:

(b) The following individuals may provide services, within their defined scopes of practice or as otherwise permitted by law:

(1)	Creative arts therapists;
(2)	Family advisors;
(3)	Licensed practical nurses;
(4)	Marriage and family therapists;
(5)	Mental health counselors;
(6)	Nurse practitioners;
(7)	Nurse practitioners in psychiatry;
(8)	Peer advocates;
(9)	Permit holders;
(10)	Physicians;
(11)	Physician assistants–for physical health only, except as otherwise provided in this Part;
(12)	Psychiatrists
(13)	Psychoanalysts;
(14)	Psychologists;
(15)	Registered professional nurses;
(16)	Social workers;
(17)	Students, provided they are participating in a program approved by the New York State Education Department that leads to a degree or license in one of the clinic’s professional disciplines, and in accordance with the following:

(i)	Students must be supervised and evaluated according to a signed agreement between the clinic provider and a New York State Education Department–approved educational program, and pursuant to the clinic provider’s policies and procedures for student placements and clinical supervision;
(ii)	Students must be part of a staffing plan that is approved by the Office;

(18)	Non–licensed staff is limited to the provision of [Outreach and] Crisis Intervention services pursuant to this Part, except as provided in subdivisions (d) or (e) of this section.

(c)  All clinic staff of providers licensed solely under Article 31 of the Mental Hygiene Law who are directly involved in providing services shall submit to criminal background checks[, and].  All clinic staff with the potential for regular and substantial contact with children in performance of their duties shall submit to clearance by the New York Statewide Central Register of Child Abuse and Maltreatment.  Clinic staff members who have not been screened by the New York Statewide Central Register of Child Abuse and Maltreatment, shall not perform duties requiring contact with children unless there is another staff member present. 

9.  Subdivision (j) of Section 599.10 of Title 14 NYCRR is amended to read as follows:

(j) The periodic review of the treatment plan shall include the following:  

(1)	assessment of the progress of the recipient in regard to the mutually agreed upon goals in the treatment plan;
(2)	adjustment of goals and treatment objectives, time periods for achievement, intervention strategies or initiation of discharge planning, as appropriate;
(3)	determination of continued homebound status, where appropriate; and
(4)	for recipients receiving services reimbursed by Medicaid on a fee–for–service basis, the signature of the physician.  For recipients receiving services that are not reimbursed by Medicaid on a fee–for–service basis, the signature of the physician, licensed psychologist, LCSW, or other licensed individual within his/her scope of practice involved in the treatment.

10.  Subdivisions (b), (e) and (h) of Section 599.13 of Title 14 NYCRR are amended to read as follows:

(b)  A weight for each clinic procedure shall be established by the Office which reflects the relative anticipated resource utilization for such procedure.  For some procedures, fees shall be enhanced pursuant to Section 599.14 of this Part through the use of billing modifiers for such things as procedures delivered [off–site,] after hours, services provided in languages other than English, and services of a minimum duration of 15 continuous minutes delivered by a physician or nurse practitioner in psychiatry. 

(e) Payments for procedures will be determined by multiplying the assigned weight for the appropriate procedure code set forth at 10 NYCRR Part 86 by the base fee, and adjusting such fee for modifiers and discounts, as appropriate. When a modifier or discount is expressed as a percentage, it will adjust the payment by its percentage of the procedure weight.  When more than one procedure applies to a visit, the highest value procedure shall be paid at its full fee value.  Payments for additional procedures related to the visit will be discounted by 10 percent.  Payments will be reduced by 25 percent for any visit in excess of 30, excluding crisis visits, off–site visits, complex care management, and any services that are counted as health services, provided during a state fiscal year to any individual who is 21 years of age or older on the first day of such fiscal year, and 50 percent for any visit in excess of 50, excluding crisis visits, off–site visits, complex care management, and any services counted as health services, provided during such fiscal year to any recipient, for fiscal years commencing on or after April 1, 2011.

(h)  Providers licensed solely under Article 31 of the Mental Hygiene Law shall be classified by the following peer groups.  During the transition to the reimbursement methodology established in this Part, the fee paid to new clinics, or clinics commencing service in a new county, shall be equal to that of the lowest blended rate in the appropriate peer group.

(1)	Upstate: All non–Local Governmental Unit operated mental health clinics operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the upstate peer group: Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, and Yates counties.
(2)	Downstate: All non–Local Governmental Unit operated mental health clinics operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the downstate peer group:  Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester counties.
(3)	Local Governmental Unit–Operated: All mental health clinics operated by a local governmental unit which are operating solely under an operating certificate from the Office.
(4)	State–operated:  All hospital–based mental health clinics operated by the Office.

11.  Paragraph (3) of subdivision (m) of Section 599.13 of Title 14 NYCRR is amended to read as follows:

(3)        During the transition, procedures will be reimbursed as a blended rate or full procedure code based rate pursuant to the following table:

Blend	Full Procedure Code	Office of Mental Health Service Name
	X	Complex Care Management
	X	Crisis Intervention Service – Brief
	X	Crisis Intervention Service – Complex
	X	Crisis Intervention Service – Per Diem
	X	Developmental and Psychological Testing
	X	Injectable Psychotropic Medication Administration – No Time Limit
	X	Injectable Psychotropic Medication Administration with Monitoring and Education – Minimum of 15 Minutes
	X	Psychotropic Medication Treatment – [No Time Limit] Minimum of 15 Minutes
X		Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development
X		Psychiatric Assessment–Minimum of 30 Minutes
X		Psychiatric Assessment–Minimum of 45 Minutes
X		Individual Psychotherapy – Minimum of 30 Minutes
X		Individual Psychotherapy – Minimum of 45 Minutes
X		Group and Multifamily/Collateral Group Psychotherapy–Minimum of 60 Minutes
X		Family Therapy/Collateral w/o patient–Minimum of 30 minutes
X		Family Therapy/Collateral with patient–Minimum of 60 minutes
	X	[Outreach (off–site visit)]

12.  Subdivisions (c), (d) and (e) of Section 599.14 of Title 14 NYCRR are amended to read as follows:

(c)  Medicaid claims may be submitted for no more than [two] three services per day for any individual, not including crisis[, injectable psychotropic medication administration, psychotropic medication treatment, and health care] services.  For the purposes of this subdivision, Psychotropic Medication Treatment, Injectable Psychotropic Medication Administration, and Injectable Psychotropic Medication Administration with Monitoring and Education 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 services.

(d)  Billing services:

(1)

[Outreach.  This service can be provided in any off–site location at the clinic’s discretion to address engagement issues for recipients already admitted to the clinic or in response to a request from clients, staff, family members, or members of the community to serve individuals not receiving treatment.  No more than two outreach procedures can be provided to an individual, unless appropriately qualified licensed staff document in the record that additional outreach is clinically necessary and appropriate. Additional outreach services may be furnished in increments of up to two services if such need and appropriateness is so documented in the record.

(2)]

Assessment services consist of two types of assessment – Initial Assessment and Psychiatric Assessment.  [For adults, no] No more than three [pre–admission] initial assessment procedures [shall be reimbursed for a recipient within a 12–month period, whether they are initial assessments or psychiatric assessments] may be reimbursed by Medicaid during an episode of service.  [For children, no more than three pre–admission assessment visits shall be reimbursed for a recipient within a 12–month period.  For recipients previously served by the clinic, additional] 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)	[The first Initial Assessment interview for an adult may be provided off–site to assess homebound status or for individuals for whom the clinic documents immediate assessment is necessary. Subsequent initial assessments may be provided off–site to adults for whom the clinic documents a determination of homebound status. The location and reason for delivering the service off–site must be documented in the treatment plan.
(b)]	Initial Assessment interviews [for children may be provided off–site] provided on or after October 1, 2010, to a child off–site shall be reimbursable be 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.
[(c)](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.
[(d)](c)	Clinics may [submit a supplemental bill under the Medical Assistance physician fee schedule] bill the physician modifier when psychiatrists, [or] 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[, and may include an evaluation report or interaction with a referring physician,] 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 [may be] 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.
[(e)	A family therapy/collateral procedure without the recipient may be billed if it assists with the initial assessment of the recipient.  This session must be for a minimum of 30 minutes.]

[(3)](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.
[(iii)	Psychiatric Consultation services may be provided off–site, but no off–site modifier may be billed.]

[(4)](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.

[(5)](4)

Injectable Psychotropic Medication Administration services are reimbursed for face–to–face contact [of any duration] 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.

[(6)](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.
[(7)](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 requires face–to–face service with the recipient of a minimum duration of 30 minutes; or
(b)	Extended Individual Psychotherapy Service requires documented face–to–face service with the recipient of a minimum duration of 45 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.
(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.

[(8)](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.
[(9)](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.
[(10)](9)	Complex Care Management must be provided within five working days following a face–to–face psychotherapy or crisis service.   Only one complex care procedure shall be billed following each face–to–face psychotherapy or crisis service.  To bill Medical Assistance, this service requires at least 15 minutes of continuous time, not including standard report writing or brief follow up calls.

(e)  Modifiers.  [(1)]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.  [For adults, the off–site services modifier is available for an initial assessment to determine if the adult is “homebound”, as clinically determined by a licensed clinician.  Thereafter, the off–site modifier is only available for adults whose service record documents that they are homebound.  For children, off–site services are available for all children.  Their service record must document that the service is medically appropriate for an off–site service.]
 
Modifier Chart for Services Provided On–Site

Office of Mental Health Service Name	[Off–site]	After Hours	Language other than English	Physician /NPP
Complex Care Management	[X]	X	X
Crisis Intervention Service–Per 15 minutes	[X]	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 – When Medication is Obtained Without Cost to Clinic – No Time Limit	[X]	X	[X]
Injectable Psychotropic Medication Administration with Monitoring and Education – Minimum of 15 Minutes		X	X
Psychotropic Medication Treatment – [No Time Limit] Minimum of 15 Minutes	[X]	X	X
Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development	[X]	X	X	X
Psychiatric Assessment–Minimum of 30 Minutes	[X]	X	X
Psychiatric Assessment–Minimum of 45 Minutes	[X]	X	X
Individual Psychotherapy–Minimum of 30 Minutes	[X]	X	X	X
Individual Psychotherapy–Minimum of 45 Minutes	[X]	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	X
Family Therapy/Collateral with patient–Minimum of 60 minutes	[X]	X	X	X
[Outreach (off–site visit)]	[X]	[X]	[X]

[(2)	Clinics that provide separate off–site procedures to a collateral and a recipient in the same location and on the same day shall only bill the off–site modifier for one of the services.
(3)	Clinics that provide off–site procedures by the same staff person to multiple recipients in the same location, including multiple apartments in the same building, the same school, the same residence, etc., on the same day shall only bill the off–site modifier for one of the services.
(4)	Clinics which provide multiple off–site procedures to a recipient on the same day shall only bill the off–site modifier for one of the services.
(5)	Physicians who participate in a group session for a minimum of 15 continuous minutes shall only receive the billing modifier for one Medicaid recipient.]

13.  A new section 599.16 is added to Title 14 NYCRR Part 599 to read as follows:

599.16 Behavioral health organizations.

(a)  Programs shall cooperate with designated regional behavioral health organizations and shall be authorized pursuant to Section 33.13(d) of the Mental Hygiene Law to exchange clinical information concerning clients with such organizations.  Information so exchanged shall be limited to the minimum necessary in light of the reason for the disclosure.  Such information shall be kept confidential and any limitations on the release of such information imposed on the party giving such information shall apply to the party receiving such information.

(b)  All clinic treatment programs designated by the Office as specialty clinics serving children shall notify the designated regional behavioral health organization when a child who is covered by Medicaid managed care has been determined to have a serious emotional disturbance.  The program shall notify the behavioral health organization of such child’s diagnosis, functional limitations and demographics. 

599.TEXT.2.27.12