Section 433.429 - Psychiatric Services: Scope of Services130 CMR 433.429 describes the services that a physician or a psychiatric clinical nurse specialist (PCNS) may provide, including the limitations imposed on those services by the MassHealth agency. For all psychotherapeutic services, the majority of time must be spent as personal interaction with the member; a minimal amount of time must be spent for the recording of data.
(A)Individual Psychotherapy. The MasssHealth agency pays a physician or PCNS for individual psychotherapy provided to a member only when the physician or PCNS treats the member. This service includes diagnostics.(B)Family and Couple Therapy. The MassHealth agency pays for therapy provided simultaneously in the same session to more than one member of the same family or to a couple whose primary complaint is the disruption of their marriage, family, or relationship. Payment is limited to one fee per session, regardless of the number of family members present or the presence of a co-therapist.(C)Group Psychotherapy.(1) Payment is limited to one fee per group member with a maximum of 12 members per group regardless of the number of staff members present.(2) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment program.(D)Multiple-family Group Psychotherapy. (1) Payment is limited to one fee per group member with a maximum of ten members per group regardless of the number of staff members present.(2) The MassHealth agency does not pay for multiple-family group psychotherapy when it is performed as an integral part of a psychiatric day treatment program.(E)Diagnostic Services. The MassHealth agency pays for the examination and determination of a patient's physical, psychological, social, economic, educational, and vocational assets and disabilities for the purpose of designing a treatment plan. This service includes an initial medication evaluation.(F)Reevaluation. The MassHealth agency pays for the reevaluation of a member who has been out of treatment for at least six months. A provider may bill for a maximum of two one hour units per member per calendar year for the purpose of designing a treatment plan.(G)Long-term Therapy. The MassHealth Agency defines long-term therapy as a combination of diagnostics and individual, couple, family, and group therapy planned to extend more than 12 sessions.(H)Short-term Therapy. The MassHealth agency defines short-term therapy as a combination of diagnostics and individual, couple, family, and group therapy planned to terminate within 12 sessions.(I)Medication Review. The MassHealth agency pays for a member visit specifically for the prescription, review, and monitoring of psychotropic medication by a psychiatrist, or PCNS, or administration of prescribed intramuscular medication by a physician or a PCNS. If this service is not combined with psychotherapy, it must be billed as a minimal office visit. The MassHealth agency does not pay separately for medication review if it is performed on the same day as another service, except for psychotherapy for crisis.(J)Case Consultation.(1) The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another entity.(2) The MassHealth agency pays for case consultation only when telephone contact, written communication, and other nonreimbursable forms of communication clearly will not suffice. Such circumstances must be documented in the member's record. Such circumstances are limited to situations in which both the physician or PCNS and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of face to face communication would impede a coordinated treatment program.(3) The MassHealth agency does not pay for court testimony.(K)Family Consultation. The MassHealth agency pays for consultation with the natural or foster parent or legal guardian of a member younger than 21 years old who lives with the child and is responsible for the child's care, and who is not an eligible member, when such consultation is integral to the treatment of the member.(L)Psychotherapy for Crisis Services. The MassHealth agency pays for psychotherapy for crisis as defined as an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. (1) This service is limited to face-to-face contacts with the member; psychotherapy for crisis service via telephone contact is not a reimbursable service.(2) The need for psychotherapy for crisis services must be fully documented in the member's record for each date of psychotherapy for crisis services.(3) This service is limited to one initial unit of service and up to three add-on units of service per date of service.(M)Electroconvulsive Therapy. The MassHealth agency pays for electroconvulsive therapy only when it is provided in a hospital setting by a physician or PCNS and only when the physician or PCNS as well as the facility meet the standards set by the Massachusetts Department of Mental Health, including those relative to informed consent.(N)After-hours Telephone Service. The physician or PCNS must provide telephone coverage during the hours when the physician or PCNS is unavailable, for members who are in a crisis state.(O)Acute Hospital Inpatient Visit. A visit to a hospitalized member in an acute hospital is payable only as a hospital visit (see 130 CMR 433.415) unless at least 15 minutes of psychotherapy is provided. Payment will be made for only one visit per member per day.(P)Frequency of Treatment. The MassHealth agency pays a physician or a PCNS for only one session of a single type of service provided to an individual member on a single date of service. Return visits on the same date of service are not reimbursable except for the provision of psychotherapy for crisis services, as described in 130 CMR 433.429(L). The MassHealth agency pays a physician or a PCNS for more than one mode of therapy provided to a member during one week only if clinically justified; that is, when any single approach has been shown to be necessary but insufficient. The need for additional modes of treatment must be documented in the member's record.(Q)Child and Adolescent Needs and Strengths (CANS). Any physician or PCNS who provides individual, group, or family therapy to members younger than 21 years old must be certified every two years according to the process established by the Executive Office of Health and Human Services (EOHHS) to administer the CANS, must use the CANS during initial behavioral-health assessments before the initiation of therapy, and must update the CANS at least every 90 days thereafter during the treatment review process.Amended by Mass Register Issue S1345, eff. 8/11/2017.