OUTPATIENT PSYCHIATRIC CARE

Section 85.28 - Applicability and general requirements

OUTPATIENT PSYCHIATRIC CARE

85.28 Applicability and general requirements.

(a) Sections 85.28 and 85.29 of this Part shall only apply to outpatient psychiatric care provided by a private practicing psychiatrist.

(b) A private practicing psychiatrist is a physician who renders treatment to a patient on a fee-for-service basis and who is compensated for those services directly through the medical assistance for the needy program, except that payment for services may be made directly to a professional corporation or partnership in which the private practicing psychiatrist is a member or with which the private practicing psychiatrist is associated, or in the case of a shared health facility as provided in subdivision 8 of section 4708 of the Public Health Law.

(c) To be a covered benefit under medical assistance for the needy as provided in section 365-a of the Social Services Law, outpatient psychiatric care rendered by a private practicing psychiatrist must be provided by a qualified psychiatrist in accordance with the requirements of sections 85.28 and 85.29 of this Part.

(d) A qualified psychiatrist shall meet the requirements contained in the Social Services regulations (18 NYCRR 505.2).
 

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Section 85.29 - Maintenance of medical records

85.29 Maintenance of medical records.

(a) Private practicing psychiatrists shall maintain medical records containing information sufficient to justify the diagnosis and warrant the treatment of each medical assistance patient served.

(b) As part of this documentation, each medical record shall include:

(1) identifying information about the person treated;

(2) current diagnosis as contained in an approved nomenclature manual such as the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, 1980 (copies are available from the publisher, American Psychiatric Association, 1700 18th Street, N.W., Washington, DC 20009) or the International Classification of Diseases, 9th revision, Clinical Modification, 1978 (copies are available from the publisher, Commission on Professional and Hospital Activities, 1968 Green Road, Ann Arbor, MI 48105). Both publications are available for inspection and copying at the offices of the records access officer of the Department of Health, Corning Tower, Empire State Plaza, Albany, NY;

(3) a description of the patient's problems, strengths, conditions, disabilities and needs;

(4) a statement of the goals and objectives of treatment to address the patient's problems, disabilities and needs, including an estimate of the duration of the patient's need for treatment, a description of the proposed treatment and prognosis;

(5) progress notes providing a chronological description of the patient's progress in relation to the goals and objectives of the established plan of treatment; and

(6) a summary of the patient's condition and disposition when treatment is completed or terminated.

(c) Patient medical records shall be retained in accordance with requirements contained in Social Services regulations (18 NYCRR 540.7).
 

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Section 85.32 - Social work

85.32 Social work.

(a) Social work services may be provided by a social worker, practicing under the direct supervision of a qualified psychiatrist in private practice as part of a course of treatment provided by the supervising psychiatrist.

(b) For purposes of this section, the term social worker shall mean a person authorized pursuant to the Education Law to use the title "certified social worker."

(c) (1) A social worker may provide services only under the continuing direct supervision of a qualified psychiatrist. Such supervision must include regular communication and consultation between the social worker and the supervising psychiatrist, but shall not be construed as requiring the physical presence of the supervising psychiatrist at the time the services are being performed by the social worker. The number of social workers supervised by the supervising psychiatrist shall not exceed four.

(2) Duties and responsibilities performed by the social worker must be assigned to him by the supervising psychiatrist, within the scope of practice of the supervising psychiatrist, and appropriate to the education, training and experience of the social worker.

(3) The provision of services by a social worker must be preceded by the completion of a diagnostic evaluation of the patient by the supervising psychiatrist.

(4) The supervising psychiatrist shall be responsible for developing an overall treatment plan which integrates the social worker's study of the patient, and describes the services to be provided by the social worker.

(5) When enrolling in the medical assistance program, a supervising psychiatrist must provide the Department of Social Services with the names of any social workers for whose services he may bill.

(d) The services provided by the social worker may include the following:

(1) the taking of a social history, if taken during an office visit, which shall include all relevant information useful to the patient's treatment;

(2) making relevant visits to the patient's home and family to assure the efficacy of the supervising psychiatrist's treatment plan;

(3) counselling the patient, if counselling is done during an office visit;

(4) conducting group therapy sessions, if conducted during an office visit;

(5) submitting regular reports to the supervising psychiatrist which will keep him informed of any changes in the patient's circumstances or condition which may influence the outcome of the patient's treatment. The reports shall be retained by the supervising psychiatrist and incorporated into the patient's medical record as required to be maintained pursuant to section 85.29 of this Part.

(e) Payment and reimbursement. (1) Payment for social work services performed by a social worker shall be made only to the supervising psychiatrist. Social workers may not bill independently for their services.

(2) State reimbursement for social work services performed by a social worker shall be limited by the maximum reimbursable fees for such services.

(3) Claims submitted by a supervising psychiatrist for social work services performed by a social worker must include the name of the social worker providing such services.
 

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Section 85.33 - Nursing service

85.33 Nursing service.

(a) Where nursing care may be provided. Nursing service as medically needed shall be provided to medical assistance recipients in the patient's home or in a hospital.

(b) Who may provide nursing care. (1) Nursing care to patients in New York State shall be provided by a person possessing a license and current registration from the New York State Education Department to practice as a registered professional nurse or licensed practical nurse.

(2) Out-of-state nurses providing care to a New York State Medical Assistance patient who is temporarily located outside New York State, must be licensed and registered in the state in which they are practicing.

(c) Private duty nursing care in the hospital. Private duty nursing care in the hospital shall be provided on the recommendation of the patient's attending physician when the patient is in need of individual and continuous care beyond that available by the staff of a hospital, including that which is available in a critical care area.

(d) Nursing service in the home. (1) For necessary nursing service to be provided in the person's home, full and primary use shall be made of the services of an approved home health agency, including a hospital-based home health agency.

(2) Such service shall be provided on a per visit basis and may include not only intermittent or part-time nursing service for the patient but also instructions to members of the patient's family in procedures necessary for the care of the patient.

(3) Service of a registered professional nurse or of a licensed practical nurse on a private practitioner basis may be provided to a patient in his or her own home only under the following circumstances:

(i) when there is no approved home health agency available to provide the intermittent or part-time nursing services need by the patient; and

(ii) when the patient is in need of individual and continuous nursing care beyond that available from an approved home health agency.

(e) Prior approval and prior authorization. Prior approval by the local professional director and prior authorization by the local social services official shall be required for nursing service provided in a person's home or in a hospital by a private practicing registered professional or licensed practical nurse, except that in an urgent situation the attending physician may order the service of such nurse for no more than two nursing days and immediately notify the local social services official and the appropriate medical director.

(f) Physician's written order required. All nursing services provided in the patient's home or in a hospital shall be in accordance with the attending physician's written order and plan of treatment; however, in extraordinary circumstances and for valid reasons which must be documented, nursing service in the home may be initiated by a home health agency before the physician sees the patient. A physician's written order is required for all such nursing services in excess of the initial two visits.

(g) Reimbursement. (1) Reimbursement for nursing services rendered by a registered professional nurse or licensed practical nurse on a private practitioner basis shall be in accordance with fees developed by the Department of Health and approved by the State Budget Director.

(2) Reimbursement shall not be allowed on a fee paid to a legally responsible relative who provides nursing services in the patient's home or in a hospital.

(3) Payment for nursing services provided by an approved home health agency, including a hospital-based home health agency, shall be at rates established by the State Commissioner of Health pursuant to subdivision 7 of section 206 of the Public Health Law and reimbursement for such expenditures shall be at such rates.
 

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Section 85.34 - Rehabilitation services

85.34 Rehabilitation services.

(a) Provision of care. Rehabilitation services shall be made available, only at the direction of a physician, to eligible persons as medically needed and as an integral part of a comprehensive medical care program. Such services include not only service to the patient but also instructions to responsible members of the family in follow-up procedures necessary for the care of the patient.

(b) Where care may be provided. Rehabilitation services may be provided in the patient's own home, in a hospital outpatient department, in an approved clinic or outpatient medical facility not part of a hospital, in an approved medical institution or facility, in an approved home health agency, or in the office of a qualified private practicing therapist or speech pathologist.

(c) Who may provide care. Rehabilitation services shall be provided by:

(1) qualified professional personnel employed by:

(i) an approved home health agency;

(ii) a hospital; or

(iii) an approved clinic or outpatient medical facility not part of a hospital;

(2) a qualified private practicing therapist or speech pathologist.

(d) Definitions. (1) Qualified professional shall mean:

(i) an occupational therapist, physical therapist or speech pathologist who is licensed and currently registered with the New York State Education Department;

(ii) an occupational therapist or physical therapist who possesses a limited permit and practices under the supervision of the appropriate professional in accordance with requirements of section 7905 and section 6735, respectively, of the State Education Law, book 16, McKinney's Consolidated Laws of New York. Copies are available from West Publishing Co., St. Paul, MN, and copies of both sections are available for inspection and copying at the offices of the records access officer of the Department of Health, Corning Tower, Empire State Plaza, Albany, NY;

(iii) a speech pathologist who is in the process of obtaining a license and has on file a "Notification of Approval of the Supervisory Plan" in accordance with requirements of the State Education Law; or

(iv) an out-of-state occupational therapist, physical therapist or speech pathologist meeting the certification requirements of the appropriate agency of the state in which they practice.

(e) Use of rehabilitation resources. (1) In the provision of necessary occupational therapy, physical therapy and speech pathology, full and primary use shall be made of qualified rehabilitation therapists employed on the staff of an approved home health agency or approved rehabilitation clinic as part of a rehabilitation team under the overall direction of a qualified physician.

(2) Service of a qualified occupational therapist, physical therapist or speech pathologist, provided on a private practitioner basis, may be rendered to a patient in his or her own home, in an approved medical facility or in the office of the therapist or speech pathologist, only under the following conditions:

(i) when there is no approved home health agency available to provide the service needed by the patient; or

(ii) when the patient is in need of individual rehabilitation service beyond, or in addition to, that which is available from an approved home health agency.

(f) Prior approval and prior authorization. (1) Prior approval by the local professional director and prior authorization of the local social services official shall be required for the following:

(i) rehabilitation services provided by a private practicing occupational therapist, physical therapist or speech pathologist; and

(ii) all out-of-state rehabilitation services.

(2) Authorization to a private practicing occupational therapist, physical therapist and speech pathologist shall not exceed three months.

(g) Physicians, written order required. (1) All rehabilitation services shall be supported by a written order of a qualified physician and shall be carried out under his or her medical direction. The written order shall constitute medical direction of the physician.

(2) Such written order shall include a diagnostic statement and purpose of treatment.

(3) Such written order is required prior to treatment.

(4) In extraordinary circumstances and for valid reasons which must be documented, a rehabilitation evaluation in the home may be initiated by a home health agency without a written order of a physician. Reimbursement shall not be made for more than one such rehabilitation evaluation visit to a patient in his own home before a physician's specific written order for treatment is obtained.

(h) Reimbursement. Reimbursement for rehabilitation services shall be made in accordance with rates and fees developed by the New York State Department of Health and approved by the New York State Division of the Budget.

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Section 85.35 - Podiatry services

85.35 Podiatry services. (a) Qualified podiatrist.

(1) A podiatrist qualified to participate in the medical assistance program means a podiatrist who is licensed and currently registered to practice podiatry in New York State by the State Education Department.

(2) Podiatry services provided to eligible medical assistance patients while temporarily out-of-state shall be provided by podiatrists qualified to practice podiatry by the appropriate licensing agency of the state in which podiatry services are provided.

(b) Podiatry services included as covered benefits. (1) Podiatry care, services and supplies shall be made available as medically needed and as an integral part of comprehensive medical care.

(2) Necessary podiatry care, services and supplies means those services provided by qualified podiatrists.

(3) Podiatry care, services and supplies shall also include the provision of, or ordering of, clinical laboratory tests that are related to the scope of podiatric practice permitted under provisions of article 141 (Podiatry) of the State Education Law, book 16, McKinney's Consolidated Laws of New York, West Publishing Co., St. Paul, MN, and the rules and regulations of the State Education Department (8 NYCRR Part 65). Copies of these statutory and regulatory provisions are available for inspection and copying at the offices of the records access officer of the Department of Health, Corning Tower, Empire State Plaza, Albany, NY.

(4) Clinical laboratory tests provided or ordered by qualified podiatrists shall be limited to those tests necessary for the diagnosis or treatment of conditions of the foot. Such tests, when performed in the office of the podiatrist in the course of treatment of his own patients, shall be limited to:

(i) complete blood count or any of the separate components of such analysis, including red cell count, white cell count, or hemoglobin;

(ii) hematocrit;

(iii) sedimentation rate;

(iv) urine analysis, routine chemical; and

(v) urine analysis, routine microscopic.

(5) All other necessary clinical laboratory tests shall be performed in a clinical laboratory holding a valid clinical laboratory permit issued in accordance with provisions of the Public Health Law, in the categories for which payment is requested from medical assistance program funds.

(6) All necessary radiologic procedures shall be made available as a covered benefit. Radiologic procedures mean X-rays used to establish a podiatric diagnosis or foot-related medical problem and may be used in conjunction with necessary treatment of foot conditions.

(c) Podiatry service limitations. (1) Medical assistance podiatry care, services and supplies shall not include:

(i) routine hygienic care of the feet in the absence of pathology;

(ii) clinical laboratory tests except those permitted in paragraphs (b)(4) and (5) of this section;

(iii) radiologic procedures outside the scope of podiatric practice as per paragraph (b)(6) of this section;

(iv) amputations and bunion operations, unless such procedures are provided in a hospital; or

(v) all podiatric prostheses in excess of $100 unless prior approval of the local professional director and prior authorization of the local social services commissioner is given.

(d) Reimbursement. Reimbursement for podiatry services shall be made in accordance with fees developed by the New York State Department of Health and approved by the New York State Division of the Budget.
 

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Section 85.36 - Licensed midwife services

85.36 Licensed midwife services. (a) Definitions. As used in this section:

(1) Licensed midwife means a person who is granted a licensed by the State Education Department and provides care pursuant to Article 140 of the State Education Law.

(2) Licensed midwife services means those services which are concerned with the management of the care of mothers and newborns throughout the maternity cycle as well as primary preventive reproductive health care of essentially healthy women.

(3) Maternity cycle means a period limited to pregnancy, labor, birth, and the immediate postpartum period not to exceed six weeks.

(4) Reserved.
(5) Department means the New York State Department of Health.

(b) Provision of care. Licensed midwife services shall be available as medically indicated to eligible medical assistance recipients.

(c) Who may provide care. Licensed midwife services shall be provided by a licensed midwife or by a person practicing out-of-state who meets the qualifications for participation as a midwife in the title XIX program in the state in which he or she is practicing.

(d) Where care may be provided. Licensed midwife services may be provided in a hospital on an inpatient or outpatient basis, in a treatment and diagnostic center, in the office of the licensed midwife or collaborating/consulting physician or in the recipient's home.

(e) Reserved.
(f) Reimbursement. (1) Reimbursement for services provided by an independently practicing licensed midwife shall be in accordance with fees developed by the department and approved by the State Director of the Budget.

(2) Services provided by a licensed midwife who is salaried by a medical facility that is reimbursed for services on a cost-related basis shall not be reimbursed on a fee-for-service basis if the cost for the licensed midwife's salary is included in the facility's cost based rate.
 

Effective Date: 
Wednesday, May 31, 2000
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