N.J. Admin. Code § 10:52-1.17

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52-1.17 - Utilization control; outpatient psychiatric services

(a) The following requirements in this rule were developed to help ensure the appropriate utilization of outpatient psychiatric services. These include the role of the evaluation team in relation to the patient's treatment regimen, with emphasis placed on intake evaluation, development of a plan of care, performance of periodic reviews for evaluation purposes, and supportive documentation for services rendered. Outpatient psychiatric services include the initial evaluation; individual psychotherapy; group psychotherapy; family therapy; family conference; partial hospitalization (see 10:52-2.10); psychological testing; and medication management.

(b) The intake evaluation shall be performed as follows:

1. An intake evaluation shall be performed within 14 days or by the third outpatient visit, whichever is later, for each Medicaid beneficiary being considered for continued treatment, and shall consist of a written assessment that:

i. Evaluates the beneficiary's mental condition; and

ii. Determines whether treatment in the program is appropriate, based on the patient's diagnosis; and,

iii. Includes certification (signed statement) by the evaluation team that the program is appropriate to meet the patient's treatment needs; and,

iv. Is made part of the patient's records.

(c) The evaluation team requirements shall be as follows:

1. The evaluation team for the intake process shall include, at a minimum, a physician and an individual experienced in diagnosis and treatment of mental illness (both criteria can be satisfied by the same individual, if appropriately qualified, in accordance with 42 CFR 441.153) .

(d) The plan of care requirements shall be as follows:

1. A written individualized plan of care shall be developed by the evaluation team for each patient who receives continued treatment. The plan of care shall be included in the patient's records and shall be designed to improve the patient's condition to the point where continued participation in the program (beyond occasional maintenance visits) is no longer necessary. The plan of care shall consist of the following:

i. A written description of the treatment objectives which include the treatment regimen, the specific medical and remedial services, therapies, and activities that will be used to meet the objectives;

ii. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter;

iii. A description designation of the type of personnel that will be furnishing the services; and,

iv. A projected schedule for completing reevaluations of the patient's condition and updating the plan of care.

(e) Documentation for outpatient psychiatric services shall be as follows:

1. For psychiatric services, the outpatient department shall develop and maintain written documentation to support each medical or remedial therapy, service, activity or session for which billing is made. Such documentation shall include, at a minimum, the following:

i. The specific services rendered, such as individual psychotherapy or family therapy;

ii. The date and the actual time services were rendered;

iii. The duration of services provided, such as 1 hour or 1/2 hour;

iv. The signature of the practitioner who rendered the services;

v. The setting in which services were rendered; and,

vi. A notation of unusual occurrences or significant deviations from the treatment described in the plan of care.

2. Clinical progress, complications and treatment which affect prognosis or progress shall be documented in the patient's medical record at least once a week for partial hospitalization and at each patient contact or visit for other psychiatric services. Any other information important to the clinical picture, therapy and prognosis shall also be documented.

i. The individual services provided under partial hospitalization shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, shall be made at least once a week.

3. For services requiring prior authorization, such as partial hospitalization (see 10:52-2.11) , a departure from the plan of care requires a new request for prior authorization when a change in the patient's clinical condition necessitates an increase in the frequency and intensity of services or change in the type of services which will exceed the services authorized.

(f) Periodic reviews shall be conducted as follows:

1. The evaluation team shall periodically review the patient's plan of care on a regular basis (at least every 90 days) to determine:

i. The patient's progress toward the treatment objectives;

ii. The appropriateness of the services being furnished; and

iii. The need for the patient's continued participation in the program.

2. The periodic reviews should be documented in detail in the patient's records and made available upon request of the Division or its agents.

N.J. Admin. Code § 10:52-1.17

Recodified from N.J.A.C. 10:52-1.15 by R.1998 d.564, effective 12/7/1998.
See: 30 N.J.R. 1257(a), 30 N.J.R. 4225(a).
Recodified from N.J.A.C. 10:52-1.16 and amended by R.2000 d.29, effective 1/18/2000.
See: 31 N.J.R. 3151(a), 32 N.J.R. 276(a).
In (a) and (e), changed N.J.A.C. references; and in (b), substituted references to beneficiaries for references to recipients throughout.
Amended by R.2005 d.214, effective 7/5/2005.
See: 37 N.J.R. 436(a), 37 N.J.R. 2506(a).
Rewrote the section.
Amended by R.2011 d.010, effective 1/3/2011.
See: 42 N.J.R. 1656(a), 43 N.J.R. 43(a).
In (c)1, substituted "CFR 441.153" for "CFR 153".