B = Billed to Incorrect Service Location OR Service Type Error (Differs from Upcoding)

The service type billed must match the type of service delivered (Differs from Upcoding in that there is no financial advantage to the billing). Billing must reflect the correct program, including PROMISe# and CBH Child #, and service location.

Includes*
  • Billed to incorrect service location
  • Service type error for less or no rate differential (Example: Billed Collateral Family Therapy as Family Therapy)
References
  • Pa Code Title 55 § 1101.75. Provider prohibited acts.
C = Date Error

The date of service must be consistent between the documentation and billed claim

Includes*
  • Billed for incorrect date
  • Billed for a date of service with no documentation present but a nearby date of service with no paid claim has documentation for the same service and number of units
References
  • Pa Code Title 55 § 1101.75. Provider prohibited acts.
D = Discrepant Information

Information contained within a clinical record must be consistent. Documentation is considered discrepant when it contradicts information within the same note, other notes, or other charts, either at the same or another provider. Includes overlapping clock times, including electronic medical record (EMR) entry times. 

Includes*
  • Incorrect client name and/or identifying information
  • Incongruent information in documentation by multiple staff members involved in the case and/or interaction (Example: BSC and TSS both document being present with a family at the same time, but their documentation gives different account of events or does not acknowledge the presence of the other). In cases of two notes with discrepant content, both are coded as Discrepant and included in variance
  • Services with overlapping clock times – both notes will be included in variance
  • EMR entry times – overlaps with other service documentation will be included in variance
References
  • Pa Code Title 55 § 1101.75. Provider prohibited acts.
E = Services Provided by an Excluded Individual or Entity

Medicaid prohibits payments for services by entities or individuals who are barred from participating in federally funded healthcare programs (including Medicaid) as identified in the List of Excluded Individuals and Entities, System for Award Management, and State Medicheck lists

Includes*
  • Services provided by or supervised by an excluded individual. Includes wages and benefits paid using Medicaid funds
References

Medical Assistance Bulletin 99-11-05

G = Group Size Not Noted or Exceeds Allowable Number of Participants

The number of participants in a group must be documented on the progress note and cannot exceed the allowable number

Includes*
  • Number of participants in group not listed; Number of participants in a group exceeds allowable number
References
  • Pa Code Title 55 § 1153.2. Psychiatric Outpatient Services: Defines group psychotherapy as: “Psychotherapy provided to no less than two and no more than ten persons with diagnosed mental disorders for a period of at least 1 hour. These sessions shall be conducted by a clinical staff person.”
  • Pa Code Title 55, § 1223.2. Outpatient Drug & Alcohol Clinic Services: Defines group psychotherapy as: “Psychotherapy provided to no less than two and no more than ten persons with diagnosed drug/alcohol abuse or dependence problems for a minimum of one hour. These sessions shall be conducted by drug/alcohol clinic psychotherapy personnel under the supervision of a physician.
  • CBH Provider Notice 11/18/16: “Psychoeducational groups are permitted as part of a treatment course in programs such as Partial Hospital Programs, Intensive Outpatient Programs (IOP), Residential Treatment Facilities, Inpatient and Non-Hospital Detoxification and Rehabilitation Units, and Halfway Houses. Psychoeducational groups are not billable as stand-alone services… The maximum group size for psychoeducational groups in order to be reimbursed by CBH is 15 participants.”
H = Upcoding

Services cannot be billed by using a CPT Code or Service Type for a more expensive service than was performed

Includes*
  • Billed as a service type at a higher rate than the documented service
References
  • Pa Code Title 55 § 1101.75. Provider prohibited acts
IC = Insufficient: Clinical

All billed dates of service must have adequate documentation that reflects the treatment rendered. The content of the note must contain clinician interventions, client response, plan for future session(s), and support the duration of time billed 

Includes*
  • Clinical content does not support paid claim
  • Evaluations lack required clinical content and/or domains
  • Documentation includes general summaries of techniques used (Examples: “used CBT”; “taught mindfulness exercise”; “reviewed relaxation techniques”)
References
  • Pa Code Title 55 § 1101.51. Ongoing responsibilities of providers.
  • Pa Code Title 55 § 1153.2. ”Psychiatric Outpatient Services” Definitions, defines psychiatric evaluation as: “An initial mental status examination and evaluation of a patient provided only by a psychiatrist in a face-to-face interview with the patient. It shall include a comprehensive history and evaluation of pertinent diagnostic information necessary to arrive at a diagnosis and treatment plan, recommendations for treatment or further diagnostic studies or consultation. The history shall include individual, social, family, occupational, drug, medical and previous psychiatric diagnostic and treatment information.”
  • Pa Code Title 55 § 1153.52. ”Psychiatric Outpatient Services” Payment conditions for various services.
  • Pa Code Title 28 § 709.93. ”Standards for Licensure of Freestanding Treatment Facilities” Client records. 
  • PA Code Title 28 § 715.15 “Standards for Approval of Narcotic Treatment Program” Medication dosage. Standards for Approval of Narcotic Treatment Programs: “(a) A narcotic treatment program may not administer an agent to a patient at a dose that exceeds that permitted by Federal regulations without the program physician’s rationale documented in the patient chart.” 
  • Pa Code Title 55 § 5230.63. “Psychiatric Rehabilitation Services” Daily entry: “PRS agency shall include an entry for the day service was provided in the record of an individual as follows: (1) Indicates the date, time, duration, location and type of interaction. (2) Documents service provided in the context of the goal. (3) Documents the individual response to service. (4) Includes the signature of the individual, or if the individual does not sign, documents the reason. (5) Is signed and dated by staff providing the service.”
  • Medical Assistance Bulletin 29-02-03, 33-02-03 Documentation and Medical Record Keeping. Requirements: “The documentation of treatment or progress notes, at a minimum, must include: (1) The specific services rendered; (2) The date that the service was provided; (3) The name(s) of the individuals(s) who rendered the services; (4) The place where the services were rendered; (5) The relationship of the services to the treatment plan, specifically any goals, objectives and interventions; (6) Progress at each visit, any change in diagnosis, changes in treatment and response to treatment;
  • Medical Assistance Bulletin 29-02-04, 33-02-04, 50-02-02 (BHRS) outlines the expectations of a, “clear, accurate, and concise” evaluation. Providers should ensure the evaluation also encompasses all the elements of the CBE/CBR
  • OMHSAS Bulletin 02-01 The Use of Seclusion and Restraint in Mental Health Facilities and Programs: “(D) Debriefing and Review of Incident: The following procedures should be followed after any use of seclusion or restraint. A review of incident between consumer and primary therapist or treating psychiatrist; and a review of the incident between involved staff & supervisor.”
  • CBH Provider Bulletin #09-01 REVISED dated 1/01/09 states, “a CBE/CBR is not considered complete and therefore not billable as a CBE or CBR until the licensed psychologist or psychiatrist has completed the clinical formulation and signed the evaluation”
ID = Insufficient: Documentation

Documentation must contain required elements

Includes*
  • Documentation is missing required elements:
    • Lacks date of service
    • Lacks original, non-photocopied signature
    • Contains signatures that are photocopied or pre-printed
    • Documentation is not original (photocopy)
    • Client not identified on each page
    • Illegible
    • Signatures, if not legible, should be accompanied by a printed name or name stamp
    • Note was not completed, signed, and/or entered into the clinical record within seven days or before the claim was submitted to CBH, whichever occurred first
    • Improper corrections
    • Client identifying information not clearly documented on all pages in the clinical record
    • Document lacks required signature(s)
    • Documentation lacks required co-signature(s) for interns
    • Lacks Encounter Form (for recipient verification of service) for required level of care
References
  • Pa Code Title 55 § 1101.51. Ongoing responsibilities of providers, (e)(1)(i), “The record shall be legible throughout.”
  • Pa Code Title 55§ 1101.51. Ongoing responsibilities of providers, (e)(1)(ii), “The record shall identify the patient on each page.”
  • Pa Code Title 55§ 1101.51. Ongoing responsibilities of providers, (e)(1)(iii): “Entries shall be signed and dated by the responsible licensed provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed and dated.” 
  • Pa Code Title 55 § 1101.66a. Clarification of the terms ‘‘written’’ and ‘‘signature’’—statement of policy: “(c) The term ”signature” in § 1101.66(b)(2) includes a handwritten or electronic signature that is made in accordance with the Electronic Transaction Act (73 P. S. §§ 2260.101—2260.5101).”
  • Pa Code Title 28 § 709.93. ”Standards for Licensure of Freestanding Treatment Facilities” Client records. § 709.93. Client records. “(5) There should be a progress note after each significant client contact which should be dated and signed by the individual making the entry.”
  • Pa Code Title 28 § 715.23 “Standards for Approval of Narcotic Treatment Program” Patient Records (e) “Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms.”
  • Pa Code Title 55 § 3800.242. “Child Residential and Day Treatment Facilities” Child records. “(b) Entries in a child’s record shall be legible, dated and signed by the person making the entry.”
  • Pa Code Title 55 § 5200.41. “Psychiatric Outpatient Clinics” Records: (b)(4), states that records shall be “signed and dated by the staff member writing in the record.”
  • Pa Code Title 55 § 5200.41 “Psychiatric Outpatient Clinics” Records: (b)(1) states records shall be, “Legible and permanent.” 
  • Pa Code Title 55 § 5210.26. “Partial Hospitalization” Records: (b)(4), states that adult records shall be “signed and dated by the staff member writing in the record.”
  • Pa Code Title 55 § 5210.26. “Partial Hospitalization” Records: (b)(1) states adult records shall be, “Legible and permanent.” 
  • Pa Code Title 55 § 5221.33. “Mental Health Intensive Case Management” Intensive case management records “(4) Documentation of services. (i) Case notes. The case notes shall: (A) Be legible.; (B) Verify the necessity for the contact and reflect the goals and objectives of the intensive case management service plan.; (C) Include the date, time and circumstance of contacts, regardless of whether or not a billable service was provided.; (D) Identify the consumer by name or case number on both sides of each page on which there is writing on both sides. The consumer’s name and case number should appear together earlier in the file.; (E) Be dated and signed by the individual providing the service.”
  • Pa Code Title 55 § 5230.22. “Psychiatric Rehabilitation Services” Documentation standards and record security, retention and disposal. 
  • Pa Code Title 55 § 5310.51. “Community Residential Rehabilitation Services for the Mentally Ill” Case record: “(c) Client case records must be:(1) Legible and in ink or typewritten.”
  • BHS/CBH Provider Bulletin September 1, 2000(f) “All clinical notes written by students must be identified as being written by a student, and counter-signed by the student’s supervisor.”
M = Missing Documentation

The clinical record must be complete and accurate. Treatment progress notes, signed and dated by the individual providing the service, shall be completed for each service provided 

Includes*
  • Progress notes and evaluation documents not filed in clinical record
  • Does not include missing treatment plans, which are listed under the code for “Treatment Plan concerns”
References
  • Pa Code Title 55 § 5200.41. “Psychiatric Outpatient Clinics “Records: (a)(8) states records shall include, “Treatment progress notes for each contact.” 
  • Pa Code Title 55 § 5210.26. “Partial Hospitalization” Records. (a)(8) states adult records shall include, “Treatment progress notes for each contact.” 
  • Pa Code Title 55 § 5210.35. “Partial Hospitalization” Contents and review of a comprehensive treatment plan. (a)(4) states treatment plans for children and youth shall, “be maintained and updated with signed daily notes, and kept in the patient’s medical record on a form developed by the facility.”
  • Pa Code Title 28 § 709.93. ”Standards for Licensure of Freestanding Treatment Facilities” Client records. (5) Clients records shall include “Progress notes.”
  • Pa Code Title 28 § 709.93. ”Standards for Licensure of Freestanding Treatment Facilities” Client records. (5) “There should be a progress note after each significant client contact which should be dated and signed by the individual making the entry.”
  • Medical Assistance Bulletin 11-90-08 Inpatient Hospital Services Retrospective
    Review Findings: “The complete medical record is an essential component of good patient care. It is used extensively to evaluate the services and quality of care rendered to patients, and must accurately, legibly, and completely reflect the chronological evaluation and treatment of the patient. The medical record must speak for itself; if something is not documented, the presumption for review purposes will be that it did not happen… Information recorded on itemized bills, invoices, MA87 forms or presented by telephone must concur with the medical record documentation.”
  • CBH Provider Bulletin #10-02 dated 1/11/10 states, “Effective February 11, 2010 all residential treatment providers are required to have documentation on a daily basis that describes the treatment that was provided by the provider to the service recipient on that day. Providers are reminded treatment described must correlate with the individual’s Treatment/Recovery Plan. This should include clear evidence that treatment is provided for every billed day.”
N = Non-Billable Activity

All billed services must be reimbursable by Medicaid

Includes*
  • Billed for an activity not reimbursable by Medicaid, including travel, homework assistance, recordkeeping activities, completing paperwork
  • Providing inappropriate services for level of care (Examples: providing psychoeducation in an outpatient group; BSCs providing therapy; Therapists performing case management)
  • Services provided to a member without a Medicaid required diagnosis
  • Services that do not meet minimum time requirements
References
  • Pa Code Title 55 § 1153.2. “Psychiatric Outpatient Services” Definitions, defines psychiatric clinic medication visit as: “A minimum 15-minute visit only for administration of a drug and evaluation of a patient’s physical and mental condition during the course of prescribed medication. This visit is provided to an eligible recipient only by a psychiatrist, physician, registered nurse or licensed practical nurse who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing.”
  • Pa Code Title 55 § 1153.2. “Psychiatric Outpatient Services” Definitions, defines family psychotherapy as: “Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental disorder. Sessions shall be at least 1/2 hour in duration and shall be conducted by a clinical staff person.”
  • Pa Code Title 55 § 1153.2. “Psychiatric Outpatient Services” Definitions, defines group psychotherapy as: “Psychotherapy provided to no less than two and no more than ten persons with diagnosed mental disorders for a period of at least 1 hour. These sessions shall be conducted by a clinical staff person.”
  • Pa Code Title 55 § 1153.2. “Psychiatric Outpatient Services” Definitions, defines individual psychotherapy as: “Psychotherapy provided to one person with a diagnosed mental disorder for a minimum of 1/2 hour. These sessions shall be conducted by a clinical staff person”
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(1) states that “Payment will not be made for the following types of services regardless of where or to whom they are provided: (1) A covered clinic or partial hospitalization service conducted over the telephone.”
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(6) states that payment will not be made for “Services delivered at locations other than approved psychiatric outpatient clinics or partial hospitalization facilities with the exception of home visits under the conditions specified in § 1153.52(d) (relating to payment conditions for various services).” This includes billing for group trips to professional sporting events, parks museums, etc. in partial hospitalization programs.
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(7) states that payment will not be made for “Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics” regardless of where or to whom the service is provided. 
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(8) states that payment will not be made for “Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities.”
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(12) states that payment will not be made for “Drugs and biologicals and supplies furnished to psychiatric clinic or psychiatric partial hospitalization patients during a visit to the clinic or facility. These are included in the clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided in the clinic are noncompensable” regardless of where or to whom the service is provided. 
  •  Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services.(16) states that payment will not be made for “The hours that the client participates in an education program delivered in the same setting as a children and youth partial hospitalization program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the client is in direct contact with a clinical staff person.”
  • Pa Code Title 55 §1223.14 “Outpatient Drug & Alcohol Clinic Services” Noncovered Services, payment will not be made for the following types of services regardless of where or to whom they are provided: (14) Methadone maintenance clinic services provided before the date of the physician’s comprehensive medical examination, diagnosis and treatment plan; (15) Services provided without a level of care assessment for each patient prior to admission to the clinic.
  • Pa Code Title 55 §1223.14 “Outpatient Drug & Alcohol Clinic Services” Noncovered Services. (1) Nonmedical counseling consisting of supportive activities to improve an individual’s problem-solving and coping skills and intrapersonal or interpersonal development and functioning; and group recreation or group social activities, as group psychotherapy. (2) Clinic visits, psychotherapy, diagnostic psychological evaluations, psychiatric evaluations and comprehensive medical evaluations conducted over the telephone, that is, any clinic service conducted over the telephone. (3) Cancelled appointments. (6) Vocational rehabilitation; day care; drug/alcohol or Mental Health partial hospitalization; reentry programs, occupational or recreational therapy; Driving While Intoxicated (DWI) or Driving Under the Influence Programs or Schools; referral, information or education services; experimental services; training; administration; follow-up or aftercare; program evaluation; case management; central intake or records; shelter services; research; drop-in, hot-line or social services; inpatient nonhospital or occupational program services, or any other service or program not specifically identified as a covered service in Chapter 1150 (relating to Medical Assistance Program payment policies) and the Medical Assistance (MA) Program fee schedule. 
  • Medical Assistance PROVIDER HANDBOOK FOR PSYCHIATRIC AND PARTIAL HOSPITALIZATION SERVICES SECTION VII – OTHER SERVICES
    – Psychiatric Services, Partial Hospitalization Section VII-6(B) Peer Support Services Compensable Services “Phone contact, travel time, staff meetings, record-keeping activities, and other non-direct services are not compensable. Social, recreational and leisure activities are not compensable.”
  • Medical Assistance Bulletin 28-97-06 Change in Billing Procedures for Psychotherapy: “MA does not reimburse any provider for documentation time. When a provider bills for one unit of psychotherapy, MA expects the provider to render one half-hour of psychotherapy” In addition, MA does not permit providers to round -up to make full half-hour increments.”
  • OMHSAS Bulletin 13-01 Targeted Case Management (TCM) – Travel and Transportation Guidelines. Section 440.169 does not identify the time a case manager spends traveling as a component of case management services. Additionally, in Technical Assistance Tool, Optional State Plan Case Management, dated April 18, 2008, the Centers for Medicare and Medicaid Services (CMS) explained that under 42 CFR § 440.169, billable units may not be billed for time spent traveling to a beneficiary to provide a case management service. Likewise, transporting or escorting consumers to appointments or other places is not identified under 42 CFR § 440.169 as a component of case management services”
  • January 6, 1998 DPW letter to providers listing “Examples of inappropriate delivery and billing of TSS”; OMHSAS Policy Clarification #03-13 re: TSS services during OT, PT, ST services; DHS “Behavioral Health Rehabilitation Services Questions and Answers”
O = Clock Times Not Documented

For all levels of care with services measurable in units of time, documentation must include accurate start and end clock times including a.m./p.m. or military time designation.

Includes*
  • Documentation lacks start and/or end times
References
  • Medical Assistance Bulletin 29-02-03, 33-02-03 Documentation and Medical Record Keeping Requirements: “The documentation of treatment or progress notes, at a minimum, must include: The actual time in clock hours that services were rendered. For example: the recipient received one hour of psychotherapy. The medical record should reflect that psychotherapy was provided from 10:00 A.M. to 11:00 A.M.”
  • Medical Assistance Bulletin 99-97-06 Accurate Billing for Units of Service Based on Periods of Time: “Providers who have units of service defined as time specific periods must document in the patient’s record, the clock time spent providing the service (i.e. 7:15 am- 8:15 am).”
  • CBH Provider Bulletin #11-01A: Changes In Inpatient Consultation & Mental Health Outpatient Billing Codes: “Please note that PA Medicaid continues to allow for only one consultation and one follow-up. Also please note that each type of consultation has a distinct blanket authorization number which must be used in billing. In addition, the CPT codes are time specific, (e.g.40 minutes, 55 minutes), and therefore must contain a start and end time for the consultation.”

P = Service Exceeds Allowable Contacts per Time Period 

Services cannot exceed allowable number of contacts

Includes*

  • All Levels of Care Service rendered may not exceed those prescribed, or bill beyond date of discharge 
  • Per Diem LOCs: Billing on date of discharge
  • Inpatient Consultations Pa Medicaid continues to allow for only one consultation and one follow-up. 
  • Outpatient D&A Services not to exceed 5 hours per week.
  • Intensive Outpatient D&A Services provided according to a planned regimen consisting of regularly scheduled treatment sessions at least 3 days per week for at least 5 hours (not to exceed 9.75) per week.
  • BHRS Services should not exceed the amount prescribed without documentation of clinical necessity.
  • RTF Services should not exceed Medicaid-allowable therapeutic leave, hospitalization, AWOL days per stay and/or per year
References
  • Pa Code Title 55 § 1101.66. Payment for rendered, prescribed or ordered services. (a) The Department pays for compensable services or items rendered, prescribed or ordered by a practitioner or provider if the service or item is: (1) Within the practitioner’s scope of practice. (2) Medically necessary. (3) Not in an amount that exceeds the recipient’s needs. (4) Not ordered or prescribed solely for the recipient’s convenience. (5) Ordered with the recipient’s knowledge. (b) Prescriptions and orders shall be written, except telephoned prescriptions addressed in subsection (c). The written prescriptions and orders shall contain the practitioner’s: (1) Printed name. (2) Signature. (3) Professional license number.”
  • Pa Code Title 55 § 1223.53. “Outpatient Drug & Alcohol Clinic Services” Limitations on payment. Outpatient Drug & Alcohol Clinic Services. Payment is subject to the following service limitations: (1) one 15-minute clinic visit per day provided to an eligible recipient. Payment will be made for only one of the following if more than one compensable service is provided in one 24-hour period: methadone maintenance clinic visit, chemotherapy clinic visit, drug-free clinic visit or opiate detoxification clinic visit. If psychotherapy is provided on the same day as a clinic visit, payment will be made only for the psychotherapy. (5) Eight total hours of psychotherapy per patient per 30-day period. This total applies to all psychotherapy: individual, family and group. 
  • Medical Assistance Bulletin 01-95-13 JCAHO Accredited RTF: 5. THERAPEUTIC LEAVE; 6. HOSPITAL ADMISSIONS; 7. ABSENCE WITHOUT LEAVE (AW0L)
  • Medical Assistance Bulletin 01-95-12 Non-JCAHO Accredited RTF: 3. Therapeutic Leave; 4. Hospital Leave; 5. Absent Without Leave (AWOL)
  • CBH Provider Bulletin #11-01A: Changes In Inpatient Consultation & Mental Health Outpatient Billing Codes: “Please note that PA Medicaid continues to allow for only one consultation and one follow-up. Also please note that each type of consultation has a distinct blanket authorization number which must be used in billing. In addition, the CPT codes are time specific, (e.g.40 minutes, 55 minutes), and therefore must contain a start and end time for the consultation.”
Q = Services provided by an unqualified individual

Staff will meet the minimum requirements of the position description guidelines established by Federal, Commonwealth, and CBH standards, as well as the provider’s own job qualifications. 

Includes*
  • Failure to meet waiver stipulations
  • Failure to obtain required clearances
  • Failure to complete foreign degree verification
References
  • Refer to the CBH Manual for the Review of Provider Personnel Files (MRPPF) and supplement(s) for detailed information
R = Re-Use of Content

Documentation must be original and accurately describe the individual’s treatment experience for the billed service.

Includes*
  • Content is taken from a textbook or website; first time a note is seen, will allow, all future notes re-using the content will be included in the variance
  • For treatment plans, use Txplan code instead
References
  • Pa Code Title 55 § 1101.51. Ongoing responsibilities of providers.
S = Services Not Rendered

Services must be provided in order to be billed

Includes*
  • Member deceased, documented as absent, no show, present but no services provided
  • Falsified documentation
  • Forged encounter forms
References
  • PA Code Title 55 § 1101.75(a)(5) states that an enrolled provider may not, either directly or indirectly, “submit a claim for services or items which were not rendered by the provider or were not rendered to a recipient.”
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services. (3) states, “Payment will not be made for … cancelled appointments.”
  • Pa Code Title 55 § 1153.14. “Psychiatric Outpatient Services” Noncovered services. (3) states, “Payment will not be made for … covered services that have not been rendered.”
  • PA Code Title 55 §1223 “Outpatient Drug & Alcohol Clinic Services”. §1223.14 (3) Cancelled appointments. 
  • Medical Assistance Bulletin 99-10-14 Missed Appointments: “The Centers for Medicare and Medicaid Services (CMS) which is responsible for administering the Medicaid Program, has an existing policy that prohibits MA providers from billing recipients or the Medicaid agency for missed appointments. According to CMS, a missed appointment is not a distinct reimbursable Medicaid service, but a part of the provider’s overall cost of doing business.” 
  • CBH Provider Bulletin #10-02 dated 1/11/10 states, “Effective February 11, 2010 all residential treatment providers are required to have documentation on a daily basis that describes the treatment that was provided by the provider to the service recipient on that day. Providers are reminded treatment described must correlate with the individual’s Treatment/Recovery Plan. This should include clear evidence that treatment is provided for every billed day”.
T = Treatment Plan Concerns

Treatment plans must be developed, updated, and signed by all appropriate persons as required for each level of care. Refer to the Treatment Plan section of the CBH Compliance Manual for detailed information.

Services provided shall be consistent with goals and interventions identified in the current treatment plan.

Includes*
  • Missing plan to cover date of service, provided service is not prescribed on the treatment plan as a modality, plan is not signed by required parties at all or in a timely manner, lack of or re-use of content in updated sections, repeated goals without any clinical explanation of their continuation
References
  • Refer to the Treatment Plan Guide on the Compliance page of the CBH/DBH/IDS website for detailed information for each LOC.
  • PA Code Title 55 § 1153.42(b)(1)(ii) “Psychiatric Outpatient Services” The treatment plan shall include services to be provided to the patient in the clinic or partial hospitalization facility or through referral.
  • Pa Code Title 55 § 1153.52. ”Psychiatric Outpatient Services” Payment conditions for various services.
  • Pa Code Title 55 § 1223.52(a)(6) “Outpatient Drug and Alcohol Clinic Services” Treatment shall be provided in accordance with the physician’s treatment plan and updates under the supervision and direction of the physician.
  • Pa Code Title 28 § 709.92(c) “Standards for Licensure of Freestanding Treatment Facilities” The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
U = Unit Error

The units of service billed must equal the units of service documented in the clinical record.

Includes*
  • Providers who have units of service defined as time specific periods must provide the full time period in order to bill for a unit of service. Providers are not permitted to round the unit of service to the next higher unit when providing a partial unit of time. Providers are not permitted to combine partial time units to equal a full unit of service. Providers who have units of service defined as time specific periods must document in the patient’s record, the clock time spent providing the service (i.e. 7:15am to 8:15am). (Applies to all levels of care except Intensive Case Management and Resource Coordination Programs, which can round up the first unit of service)
References
  • Pa Code Title 55 § 1101.75(a)(1) states that providers may not (1) Knowingly or intentionally present for allowance or payment a false or fraudulent claim or cost report for furnishing services or merchandise under MA, knowingly present for allowance or payment a claim or cost report for medically unnecessary services or merchandise under MA, or knowingly submit false information, for the purpose of obtaining greater compensation than that to which the provider is legally entitled for furnishing services or merchandise under MA.
  • Medical Assistance Bulletin 99-97-06 “Providers who have units of service defined as time specific periods must provide the full time period in order to bill for a unit of service. Providers are not permitted to round the unit of service to the next higher unit when providing a partial unit of time. Providers are not permitted to combine partial time units to equal a full unit of service. Providers who have units of service defined as time specific periods must document in the patient’s record, the clock time spent providing the service (i.e. 7:15am to 8:15am).”
  • PA Code Title 55 §1223.52(b) “Outpatient Drug & Alcohol Clinic Services” Methadone maintenance clinic visits; 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. 
  • Pa Code Title 55 § 1153.2, “Psychiatric Outpatient Services” Definitions, defines family psychotherapy as: “Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental disorder. Sessions shall be at least 1/2 hour in duration and shall be conducted by a clinical staff person.”
Y = Unbundling Codes

Billing One Encounter as Two Service Events/Types; The provider may not, either directly or indirectly, submit a duplicate claim for services or items for which the provider has already received or claimed reimbursement. 

Includes*
  • This section includes Psychiatric Outpatient Services: “Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.”
  • Services which cannot be billed on the same day (unless clinically indicated with supporting documentation) include, but are not limited to: Assessment and CBE/CBR (at the same provider); Medication Checks and Partial Hospitalization Program; Mobile Therapy and Mental Health Outpatient; IOP and Outpatient Drug & Alcohol; Lab billing during Inpatient stay; Partial Hospitalization Program and Mental Health Outpatient.”
References
  • Pa Code Title 55 § 1101.75. Provider prohibited acts.(a)(4) ‘“An enrolled provider may not, either directly or indirectly, do any of the following: (4) Submit a duplicate claim for services or items for which the provider has already received or claimed reimbursement from a source.” 
  • Pa Code Title 55 § 1153.53(10) “Psychiatric Outpatient Services” Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.
  • Pa Code Title 55 § 1153.14(5) “Psychiatric Outpatient Services “states that payment will not be made for “Psychiatric outpatient clinic or partial hospitalization services to residents of treatment institutions, such as, persons who are also being provided with room or board or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program” regardless of where or to whom the service is provided. 
  • Pa Code Title 55 § 1153.14(9) “Psychiatric Outpatient Services “states that payment will not be made for “Psychiatric outpatient clinic services and psychiatric partial hospitalization provided on the same day to the same patient” regardless of where or to whom the service is provided. 
  • Pa Code Title 55 § 1153.14(11) “Psychiatric Outpatient Services” states that payment will not be made for “Psychiatric outpatient clinic and psychiatric partial hospitalization services provided to patients with drug/alcohol abuse or dependence problems, such as alcohol dependence and nondependent abuse of drugs, alcohol psychoses, and drug psychoses, unless the patient has a primary diagnosis of a nondrug/alcohol abuse/dependence related mental disorder” regardless of where or to whom the service is provided. 
  • Pa Code Title 55 § 1153.53(10) “Psychiatric Outpatient Services” Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.