§ 1223.52. Payment conditions for various services.
(a) Elibilty for payment. The following conditions shall be met by an outpatient drug and alcohol clinic, as applicable, to be eligible for payment:
(1) Drug/alcohol clinic visits—methadone maintenance clinic visits, chemotherapy clinic visits and opiate detoxification clinic visits—shall be provided only by a licensed physician or other drug/alcohol clinic medical personnel under the supervision of a physician. Drug-free clinic visits shall be provided by a licensed physician or by drug/alcohol clinic personnel under the supervision of a physician.
(2) A comprehensive medical examination shall be provided only by a licensed physician. Additional interviews with other staff may be included as part of the comprehensive medical examination, but shall be included in the comprehensive medical examination fee. Separate billings for these interviews are not compensable.
(3) A psychiatric evaluation shall be provided only by a licensed psychiatrist. Additional interviews with other staff may be included as part of the psychiatric evaluation, but shall be included in the psychiatric evaluation fee. Separate billings for these interviews are not compensable.
(4) Psychotherapy—individual, family or group—shall be provided only by licensed physicians or other drug/alcohol outpatient clinic psychotherapy personnel under the supervision of a physician.
(5) Diagnostic psychological services—the psychological and intellectual evaluations listed in the Medical Assistance Program Fee Schedule—shall be provided only by licensed psychologists under the supervision of a physician.
(6) With the exception of methadone maintenance clinic services, a DAAP shall perform a level of care assessment for each patient prior to admission to the clinic and the provision of services.
(i) Within 15 days following intake, the clinic’s supervisory physician shall review and verify each patient’s level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic’s supervisory physician shall verify the patient’s diagnosis. The clinic’s supervisory physician shall sign and date the patient’s level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient’s record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic’s supervisory physician’s review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient’s diagnosis.
(ii) Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic’s supervisory physician shall review and update each patient’s treatment plan. Each review and update shall be dated, documented and signed in the patient’s record by the clinic’s supervisory physician.
(iii) The treatment plan and updates shall be based upon the psychosocial evaluation and diagnoses. Treatment shall be provided in accordance with the treatment plan and updates and under the supervision and direction of the clinic’s supervisory physician. Clinic supervisory physician reviews and reevaluations of diagnoses, treatment plans and updates shall be done in the clinic.
(iv) A physician may perform a comprehensive medical examination or psychiatric evaluation, when medically necessary, as indicated by either the level of care assessment or the clinic’s supervisory physician’s review.
(7) For methadone maintenance clinics, following intake and prior to the provision of any services, the clinic’s supervisory physician shall perform a comprehensive medical examination on each patient to determine the patient’s diagnoses, initial treatment plan and identify any medical conditions. The clinic’s supervisory physician shall document and sign the comprehensive medical examination 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) Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic’s supervisory physician shall review and update each patient’s treatment plan. Each review and update shall be dated, documented and signed in the patient’s record by the clinic’s supervisory physician.
(ii) The treatment plan and updates shall be based upon the comprehensive medical examination, psychosocial evaluation and diagnoses. Treatment shall be provided in accordance with the treatment plan and updates and under the supervision and direction of the clinic’s supervisory physician. Clinic supervisory physician reviews and reevaluations of diagnoses, treatment plans and updates shall be done in the clinic.
(b) Methadone maintenance clinic visit, chemotherapy clinic visit, drug-free clinic visit and opiate detoxification clinic visit. Payment will only be made for drug/alcohol clinic visits provided to eligible drug/alcohol patients in approved drug/alcohol outpatient clinics under the following conditions:
(1) The visit shall be a minimum duration of 15 minutes.
(2) A drug or biological furnished to a clinic patient for therapeutic purposes during a clinic visit, diagnostic laboratory services used to detect the patient’s use of drugs, and supplies provided to the outpatient are included in the clinic visit fee. This paragraph does not apply to documented, medically necessary tests for pregnancy and medical conditions such as hepatitis, anemia and AIDS.
(3) The chemotherapy clinic visit is only for the purpose of administering medication, such as antabuse or tranquilizers, and for evaluating the physical and mental condition of the patient during the course of prescribed medication.
(4) The drug-free clinic visit is only for the purpose of evaluating a patient’s physical and mental condition during a course of treatment when prescribed medication such as antabuse, methadone or tranquilizers is not provided to assist in withdrawal or in maintenance.
(c) Psychotherapy. A patient receiving psychotherapy shall be diagnosed by a physician as having a drug/alcohol abuse or dependence problem, in accordance with the International Classification of Diseases, 9th Revision (ICD-9-CM). In the case of family psychotherapy, psychotherapy shall include at least one family member with a drug/alcohol abuse or dependence problem, that is, the clinic patient. Interviews or consultations with family members alone, without the presence of the family member with a drug/alcohol abuse or dependence problem, are considered to be part of the family psychotherapy fee. Separate billings for these interviews are not compensable.
(d) Home visits. The following conditions apply to payment for home visits:
(1) Payment will be made for compensable drug/alcohol clinic services provided to eligible recipients only under the following conditions:
(i) The physician certifies in his handwriting on the invoice submitted for payment that the patient is severely physically disabled, the nature of the disability and the reason why the patient could not be transported to the clinic.
(ii) The home visit is made to the patient’s private residence, foster home or home of friend or relative wherein the patient resides. A home visit is not compensable when made to an inpatient nonhospital facility, hospital, shelter, partial hospitalization facility, correctional facility or other location not specifically allowed in this subsection.
(2) Clinic services delivered in the home are subject to the conditions and limitations established in this chapter for clinic services delivered in the clinic facility.
(3) Group psychotherapy is not covered.
Authority The provisions of this § 1223.52 amended under sections 403(a) and (b), 443.3(1) and 509 of the Public Welfare Code (62 P. S. § § 403(a) and (b), 443.3(1) and 509).
Source The provisions of this § 1223.52 amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4416; amended September 30, 1988, effective July 29, 1987, 18 Pa.B. 4423; amended November 8, 2002, effective November 9, 2002, 32 Pa.B. 5513. Immediately preceding text appears at serial pages (285063) to (285065).
Cross References This section cited in 55 Pa. Code § 1223.14 (relating to noncovered services).
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