Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER PDT-19
September 2003
TO:      Psychiatric Day Treatment Programs Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner
RE:      Psychiatric Day Treatment Program Manual (Revisions to the Psychiatric Day Treatment Program Regulations and Service Codes)

This letter transmits revisions to the Psychiatric Day Treatment Program Manual. The program regulations and service codes were revised to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. New national procedure codes have been added, and MassHealth local codes have been removed from the Psychiatric Day Treatment Program Manual. Please note that you must use a modifier with some codes to accurately reflect the service provided. The attached Subchapter 6 contains codes with modifiers, where applicable.
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the regulation. Regulations may also be viewed and printed off the Division’s website free of charge at www.mass.gov/dhcfp. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for Psychiatric Day Treatment Program services is 114.3 CMR 7.00.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

Changes to Psychiatric Day Treatment Program Regulations
In addition to changes made to comply with HIPAA, the revised program regulations modify the requirements for, and describe the qualifications of, professional psychiatric day treatment program staff. Qualifications for psychiatric nurse/clinical specialists (RNCS) and licensed mental health counselors have also been added to 130 CMR 417.423.

MASSHEALTH
TRANSMITTAL LETTER PDT-19 September 2003 Page 2
Psychiatric day treatment programs must demonstrate a rehabilitation and recovery orientation. The mix of services provided must be appropriate for the needs of the member population. Treatment plans must be goal oriented, focused on the principles of rehabilitation and recovery, and time frames are to be established for the attainment of short- and long-term behavioral goals.
Language has been added to 130 CMR 417.405 that requires a separate application for certification as a psychiatric day treatment program be submitted for each parent center and satellite facility operated by the provider. In addition, any new psychiatric day treatment program must also be a Medicare-participating provider.
Language has been added to 130 CMR 417.412 that requires psychiatric day treatment programs to ensure that the member is not receiving duplicate services from any other MassHealth provider or program. Duplicate services include psychiatric day treatment programs, partial hospitalization programs, and services referenced in 130 CMR 417.440(B).
Updated Service Codes and Descriptions
Home Visits
For dates of service on or after October 1, 2003, providers will no longer bill using MassHealth local code X9196 to receive enhanced payment for home visits (direct evaluation or treatment provided for at least one hour in a member’s place of residence). Providers will bill for the home visit using the appropriate procedure code for the service performed, in conjunction with an appropriate place of service indicating a home visit. Payment for home visits will be made in accordance with the applicable fee schedule of the Division of Health Care Finance and Policy.
Billing Guidelines
For dates of service before October 1, 2003, providers are expected to use the local codes regardless of when the claim is submitted. However, for dates of service on or after October 1, 2003, providers must bill using the new national service codes from the revised Subchapter 6.
Attached to this letter is a service code crosswalk that lists the obsolete MassHealth procedure codes and their corresponding new national procedure codes for the revised Subchapter 6.
These regulations are effective October 1, 2003.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Psychiatric Day Treatment Program Manual
Pages iv, vi, vii, 4-1 through 4-20, 6-1, and 6-2

MASSHEALTH
TRANSMITTAL LETTER PDT-19 September 2003 Page 3
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Psychiatric Day Treatment Program Manual
Pages iv and 4-3 through 4-20 — transmitted by Transmittal Letter PDT-16
Pages vi, D-1, and D-2 – transmitted by Transmittal Letter PDT-17
Pages vii and vii-a – transmitted by Transmittal Letter PDT-2
Pages 4-1 and 4-2 – transmitted by Transmittal Letter PDT-18
Page 6-1 – transmitted by Transmittal Letter PDT-14

Transmittal Letter PDT-19
September 2003
Attachment
Psychiatric Day Treatment Program Service Code Crosswalk

Obsolete Code	Obsolete Code Description	New Code-Modifier	New Code Description-	CMS POS
To be used on 837P
transactions	DMA POS
To be used on
paper and
EMC
transactions	Limitation/ Comment	

	

	
	
X9188	Full-day session (period of scheduled participation by a member lasting six hours or more)	H2012	Behavioral health day treatment, per hour	11 (office), 49 (independent clinic)
52	(psychiatric facility)
53	(CMHC)	01 (office, facility, or business location)	Maximum of six units per day	
X9189	Half-day session (period of scheduled participation by a member lasting three hours or more)	H2012	Behavioral health day treatment, per hour	11, 49, 52, 53	01	Maximum of six units per day	
X9190	Quarter-day session (period of scheduled participation by a member lasting one and one-half hours or more)	H2012	Behavioral health day treatment, per hour	11, 49, 52, 53	01	Maximum of six units per day	
X9191	Admitting full-day session period of scheduled participation by a member lasting six hours or more) (initial day of service only)	H2012	Behavioral health day treatment, per hour	11, 49, 52, 53	01	Maximum of six units per day	
X9192	Admitting full-day session period of scheduled participation by a member lasting three hours or more) (initial day of service only)	H2012	Behavioral health day treatment, per hour	11, 49, 52, 53	01	Maximum of six units per day	
X9193	Admitting quarter-day session period of scheduled participation by a member lasting one and one-half hours or more) (initial day of service only)	H2012	Behavioral health day treatment, per hour	11, 49, 52, 53	01	Maximum of six units per day	
X9194	Preadmission evaluation visit (comprehensive evaluation by a professional lasting at least one hour to determine the need for psychiatric day treatment program services and to design a treatment plan)	H2012-U1	Behavioral health day treatment, per hour; preadmission evaluation visit	11, 12 (member’s home), 49, 52, 53	01, 02
(member’s
home)	Maximum of one unit per day	
X9195	Family conference session (face-to-face session lasting at least one hour with family or other responsible persons to interpret accumulated data and to advise them how to assist member)	90887	Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient	11, 12, 49, 52, 53	01, 02	Maximum of one unit per day, where one unit = one session	
X9196	Home visit (direct evaluation or treatment provided for at least one hour in a member’s place of residence)	H2012	Behavioral health day treatment, per hour	12	02	Maximum of one unit per day	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
iv	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
4.   PROGRAM REGULATIONS
417.401:	Introduction 		4-1
417.402:	Definitions 		4-1
417.403:	Eligible Members 		4-2
417.404:	Provider Eligibility 		4-3
417.405:	In-State Providers: Certification 		4-3
417.406:	In-State Providers: Reporting Requirements 		4-4
417.407:	In-State Providers: Revocation of Certification 		4-4
417.408:	In-State Providers: Maximum Allowable Fees 		4-5
417.409:	Out-of-State Providers: Maximum Allowable Fees 		4-5
417.410:	Nonreimbursable Services 		4-5
417.411:	Functional Level Review 		4-6
417.412:	Scope of Services 		4-7
417.413:	Psychiatric Day Treatment Program Services Provided to
Institutionalized Members 		4-7
417.414:	Referrals 		4-8
(130 CMR 417.415 through 417.420 Reserved)
417.421:	Staffing Requirements 		4-9
417.422:	Organizational Structure 		4-9
417.423:	Qualifications of Professional Staff 		4-11
(130 CMR 417.424 through 417.430 Reserved)
417.431:	Requirements for Admission 		4-13
417.432:	Admission Procedures 		4-13
417.433:	Treatment Planning 		4-14
417.434:	Home Visits 		4-15
417.435:	Case Management 		4-15
417.436:	Discharge from Program 		4-15
417.437:	Recordkeeping Requirements 		4-16
417.438:	Written Policies and Procedures 		4-17
417.439:	Administration 		4-18
417.440:	Service Limitations 		4-18

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
6. SERVICE CODES AND DESCRIPTIONS
Service Codes and Descriptions 		6-1
Appendix A.     DIRECTORY 		A-1
Appendix B.     ENROLLMENT CENTERS 		B-1
Appendix C.     THIRD-PARTY-LIABILITY CODES 		C-1
Appendix D.     (Reserved) 	
Appendix W.    EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE	W-1
Appendix X.     FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y.     REVS CODES/MESSAGES 		Y-1
Appendix Z.     EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
PREFACE	PAGE
vii	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
The regulations and instructions of the Division of Medical Assistance governing provider participation in MassHealth are published in the Provider Manual Series. The Division publishes a separate manual for each provider type.
Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. The Division’s regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. Regulations promulgated by the Division of Medical Assistance are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title.
Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals.
Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For psychiatric day treatment centers, those matters are covered in 130 CMR Chapter 417.000, reproduced as Subchapter 4 in the Psychiatric Day Treatment Program Manual.
Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others.
The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead the Division’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with the Division and with MassHealth members.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-1	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.401: Introduction
All psychiatric day treatment programs participating in MassHealth must comply with the regulations of the Division governing MassHealth including, but not limited to, Division regulations set forth in 130 CMR 417.000 and in 130 CMR 450.000.
417.402: Definitions
The following terms used in 130 CMR 417.000 have the meanings given in this section unless the context clearly requires a different meaning.
Freestanding Clinic — any institution licensed as a clinic by the Department of Public Health pursuant to M.G.L. c. 111, § 51 that is not part of a hospital and that has its own legal identity, maintains its own patient records, and administers its own budget and personnel. Such institutions include mental health centers and community health centers.
Functional Level — the degree to which an individual can function independently in the community. Progressive levels of impaired functioning are evaluated using a Division-approved outcome measure (which includes criteria set forth in 130 CMR 417.411).
Functional Maintenance Program — a planned combination of social, vocational, and recreational services designed for individuals disabled by a chronic mental illness who need continuing services to maintain skills that allow them to function within the community but who do not require the more intensive care of inpatient or day treatment programs.
Hospital-Licensed Health Center — a facility not physically attached to a hospital that operates under that hospital's license, that falls under its fiscal, administrative, personnel, and clinical management, and that provides services to members on an outpatient basis, such as hospital-licensed community health centers and mental health centers.
Identifiable Unit — a separate organizational unit within the same building as, but separately established from, the facility of which it is part that employs staff explicitly assigned to it, and has separately defined and established purposes, policies, procedures, and treatment services.
Mental Illness — mental and emotional disorders as defined in the current International Classification of Diseases, Clinical Modification, or the American Psychiatric Association's Diagnostic and Statistical Manual, and manifested by impaired functioning in one or more of the following: emotional stability, vocational/educational productivity, social relations, and self-care.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-2	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
Psychiatric Day Treatment Program (the program) — a planned combination of diagnostic, treatment, and rehabilitative and recovery-oriented services provided to mentally or emotionally disturbed persons who need more active or inclusive treatment than is typically available through a weekly visit to a mental health center or hospital outpatient department, but who do not need full-time hospitalization or institutionalization. Such a program utilizes multiple, intensive, and focused activities in a supportive environment to enable such persons to acquire more realistic and appropriate behavior patterns, attitudes, and skills for eventual independent functioning in the community. Such programs may be operated by a freestanding clinic, a satellite facility of a clinic, a hospital-licensed health center, or an identifiable unit of a clinic, hospital, or hospital-licensed health center.
Satellite Facility — a facility not physically attached to a clinic that operates under the clinic's license and that falls under its fiscal, administrative, personnel, and clinical management.
Sheltered Workshop — a program of vocational counseling and training in which the participants receive paid work experience or other supervised employment.
Vocational Rehabilitative Services — services that provide vocational assessments, job training, career counseling, and job placement.
417.403: Eligible Members
(A)	(1) MassHealth Members. The Division covers psychiatric day treatment program services
only when provided to eligible MassHealth members, subject to the restrictions and
limitations described in the Division’s regulations. The Division’s regulations at 130 CMR
450.105 specifically state, for each MassHealth coverage type, which services are covered and
which members are eligible to receive those services.
(2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
(C)	See 130 CMR 450.124 for limitations on mental health and substance-abuse services provided
to members enrolled with a MassHealth managed-care provider.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-3	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.404: Provider Eligibility
(A)	In State. The Division pays only for services described in 130 CMR 417.000 provided by
a psychiatric day treatment program that participates in MassHealth on the date of service and
meets the following criteria:
(1)	the program operates under a valid clinic or hospital license issued by the Massachusetts Department of Public Health for the provision of services at its location, and is a Medicare-participating provider;
(2)	the program is open at least three days a week, but if it is open less than five days a week, it must develop and institute plans for expanding the program to five days a week within six months of certification; and
(3)	on each day that the program is open, it operates for at least six hours but less than 24 hours.
(B)	Out of State. The Division pays only for services provided by an out-of-state psychiatric day
treatment program that obtains a MassHealth provider number and meets the following criteria:
(1)	the program is licensed by the appropriate state agency under whose jurisdiction it operates;
(2)	the program participates in its state's Medicaid Program or the equivalent of that program;
(3)	the program has a per diem rate established by its state's appropriate rate setting regulatory body; and
(4)	the program is a Medicare-participating provider.
417.405: In-State Providers: Certification
(A)	A separate application for certification as a psychiatric day treatment program must be submitted for each parent center and satellite facility operated by the provider. The application must be made on a form provided by the Division. The application must include all pertinent information necessary for the Division to evaluate the program's compliance with the requirements contained in 130 CMR 417.000.
(B)	The Division reviews applications and conducts site inspections to determine compliance with these regulations. The Division may request the assistance of the Massachusetts Department of Mental Health in evaluating a program.
(C)	The Division determines from the application and site visit whether to certify the applicant, and conveys its decision in writing to the applicant within 60 days of the site visit. If the application for certification is denied, the notice states the reasons for the denial, recommendations for corrective action, and an assessment of the applicant's prospects for certification once corrective action has been taken.
(A)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-4	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.406: In-State Providers: Reporting Requirements
All psychiatric day treatment programs must complete and submit a Uniform Financial Report annually to the Division according to the Audit and Preparation Manual section of the Uniform Financial Report for the given year.
417.407: In-State Providers: Revocation of Certification
(A)	The Division may review a psychiatric day treatment program's continued compliance with the requirements set forth in 130 CMR 417.000 upon reasonable notice and at any reasonable time during the program's hours of operation. If deficiencies are observed during such a visit, the Division sends the program a letter itemizing these deficiencies. The psychiatric day treatment program must then submit a plan of correction for all deficiencies cited in the letter, including the specific corrective steps to be taken, a timetable for these steps, and the date by which full compliance is to be achieved, which must be no later than three months from the date of the Division’s letter.
(B)	The Division may revoke the certification of a program if the program fails to submit an acceptable plan of correction or fails to implement it, subject to any applicable provisions of the Division’s administrative and billing regulations at 130 CMR 450.000.
(C)	The Division may also revoke certification at any time, if in its judgment the program has failed to or ceased to meet its obligations as set forth in 130 CMR 417.000.
(D)	However, if the Division determines that there exists good cause for the imposition of a lesser sanction than revocation of certification, it may withhold payment, temporarily suspend the psychiatric day treatment program from participating in MassHealth, or impose some other lesser sanction as it sees fit.
(E)	Whenever the Division proposes to revoke the certification of, or impose a lesser sanction on,
a psychiatric day treatment program, the program will be given notice and an opportunity for a
hearing as set forth in the Division’s administrative and billing regulations at 130 CMR 450.000.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-5	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.408: In-State Providers: Maximum Allowable Fees
The Massachusetts Division of Health Care Finance and Policy determines the maximum allowable fees for psychiatric day treatment program services. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 417.000 and in the Division’s administrative and billing regulations at 130 CMR 450.000. Payment for a service is the lower of the following:
(A)	the psychiatric day treatment program's usual and customary fee; or
(B)	the maximum allowable fee listed in the fee schedule.
417.409: Out-of-State Providers: Maximum Allowable Fees
Payment to an out-of-state psychiatric day treatment program is in accordance with the applicable rate schedule of its state's Medicaid Program or its equivalent, and is always subject to the applicable conditions, exclusions, and limitations set forth in 130 CMR 417.000.
417.410: Nonreimbursable Services
(A)	Uncertified Programs. The Division does not pay for services that are provided as part of an uncertified psychiatric day treatment program, even if the provider participates in MassHealth.
(B)	Vocational Rehabilitative Services. The Division does not pay for any vocational rehabilitative services. However, certain prevocational activities, such as time management groups and career planning groups to prepare members for less intensive services, may be considered part of the hourly rate.
(C)	Sheltered Workshops. The Division does not pay for sheltered workshops.
(D)	Educational Services. The Division does not pay for educational services, such as traditional academic and special classroom services.
(E)	Functional Maintenance Programs. The Division does not pay for functional maintenance
programs.
(F)	Research and Experimental Treatment. The Division does not pay for research or
experimental treatment.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-6	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
(G) Services Included as Part of Treatment Sessions. The Division does not pay for the following services separately, since the fee for treatment sessions includes the cost of these services:
(1)	telephone contacts of any duration with or related to members;
(2)	any consultations about members with outside agencies;
(3)	information and referral;
(4)	patient registration;
(5)	recordkeeping;
(6)	individual service planning; or
(7)	case management.
417.411: Functional Level Review
(A)	Each psychiatric day treatment program must assess the functional level of each member at intake into the program, at the end of every other month that the member remains in the program, and at discharge from the program. The assessments must be entered on forms supplied for that purpose by the Division and completed according to the instructions contained in Subchapter 5 of the Psychiatric Day Treatment Program Manual.
(B)	The Division may decide to review a member’s treatment if examination of the member’s functional level review forms indicates that one or more of the following applies:

(1)	no progress has been made for four months;
(2)	the member has regressed on one or more levels; or
(3)	another reason deemed appropriate by the Division.
(C)	The Division conducts a utilization review on all cases reviewed by the Division for the
reasons listed in 130 CMR 417.411(B) to determine whether the case should be continued,
modified, or terminated. When the Division decides to conduct such a review, the psychiatric day
treatment program must complete Division-supplied forms that document the need for ongoing
treatment according to instructions contained in Subchapter 5 of the Psychiatric Day Treatment
Program Manual. The utilization review determines only the health care necessity of the service
and neither establishes nor waives any other prerequisite for payment, such as member eligibility
or resort to health insurance payment. The Division uses the following criteria in determining
necessity for continued treatment.
(1)	The member continues to need and will benefit from psychiatric day treatment program services in achieving short- and long-term goals.
(2)	The member has the potential to move into a less intensive level of care within a specified time period.
(D)	A representative from the psychiatric day treatment program may be required to attend
meetings convened by the Division to reevaluate the outcome measures and/or functional scaling
system.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-7	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.412: Scope of Services
(A) A psychiatric day treatment program must ensure the availability of a sufficient variety of professional and special services to meet the needs of its member population. These services may be provided by the program itself or through referral to other agencies, as set forth in 130 CMR 417.414.
(B) The program must demonstrate to the Division in its application for certification a rehabilitation and recovery orientation in which the mix of services it provides is appropriate for the needs of its member population. Appropriate services include: medical, nursing, diagnostic, pharmaceutical, self-care, and social work services; individual and group therapy; and aftercare and alumni groups. The psychiatric day treatment program must ensure that the member is not receiving duplicate services from any other MassHealth provider or program.
417.413: Psychiatric Day Treatment Program Services Provided to Institutionalized Members
(A)	The Division does not pay for psychiatric day treatment program services provided to a member who lives in the facility where these services are provided.
(B)	The Division does not pay for psychiatric day treatment program services provided to a member who receives inpatient or long-term-care services in an acute or chronic hospital, a psychiatric hospital, or a level II or level III nursing facility.
(C)	The Division pays for psychiatric day treatment program services provided to a member who lives in a rest home, halfway house, boarding home, or other congregate-care facility.
(A)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-8	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.414: Referrals
(A)	To ensure that members receive services not available from the program but required by their
comprehensive treatment plan or aftercare plan, a psychiatric day treatment program must have
effective methods to promptly and efficiently refer these members to community resources. This
requires that the staff know the resources available in the community, maintain a file of
appropriate addresses, telephone numbers, and contact persons, have standing agreements with
these resources as necessary, and prepare for and follow up referrals through case conferences,
written communications, and other less formal procedures. To ensure that such a referral system is
in effect when the program applies for certification, it must supply the Division with a description
of its referral network and the tracking system by which it coordinates these referrals for each
member and follows up on the member after the referrals are made. The program must also
document, when applicable, the components of the referral network that are not available in the
area serviced by the program.
(1)	Inpatient Psychiatric Hospital or Unit.
(a)	The program, or parent corporation, must establish a member-specific crisis plan as well as an agreement and working relationship with the local Emergency Services Program to provide expeditious access to emergency psychiatric care and hospitalization when necessary.
(b)	In areas where no inpatient psychiatric unit exists, the program must establish a transfer agreement with a general hospital, or make other arrangements for hospitalization subject to the Division’s approval, such as with a psychiatric hospital outside the area.

(2)	Ambulatory Health Care Provider. The program must establish a transfer agreement with a MassHealth-participating ambulatory care provider to provide screening, diagnosis, and treatment services.
(3)	Massachusetts Rehabilitation Commission. The program must have a documented affiliation agreement with the local office of the Massachusetts Rehabilitation Commission to provide evaluation and rehabilitation services to members approaching discharge from the program. The agreement may allow for placement of a Massachusetts Rehabilitation Commission employee on site in the psychiatric day treatment program.
(4)	Emergency Service Team. Each program must establish a transfer agreement with an emergency service team in its community.
(5)	Other Resources. The program must document the establishment of effective methods for providing its members with housing, employment, recreation, transportation, education, social services, health care, and legal services through referral to appropriate community agencies.
(B)	If the psychiatric day treatment program is operated by a community health center, the
program is deemed to be in compliance with the requirements for referral services listed in 130
CMR 417.414(A), if the community health center provides the services and the psychiatric day
treatment program has established relationships and communication with the community health
center's primary care staff.
130 CMR 417.415 through 417.420 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PSYCHIATRIC DAY TREATMENT PROGRAM MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 417.000)	PAGE
4-9	

	TRANSMITTAL LETTER
PDT-19	DATE
10/01/03	
417.421:  Staffing Requirements
(A)	Minimum Staffing Requirements.
(1)	A psychiatric day treatment program with fewer than 28 participants must be staffed at a minimum by a treatment team of three qualified professionals. At least two of the treatment team members must be employed full time by the program. The third team member may be two part-time employees or one full-time employee.
(2)	Programs with 28 participants or more must have one additional full-time professional for every eight additional participants.
(B)	Composition of the Treatment Team.
(1)	Each member of a treatment team must represent a different discipline from the other members of the same treatment team.
(2)	At least two full-time staff members of the same treatment team must be drawn from the following disciplines: psychiatry, psychology and/or counseling psychology, social work, psychiatric nursing, licensed mental health counseling, occupational therapy, or rehabilitation counseling.
(3)	The remaining members of the same treatment team may separately represent any disciplines listed in 130 CMR 417.421(B)(2) or expressive therapy or allied health.
(4)	The composition of the treatment team must be appropriate to the needs of the participants and, where possible, include participant representation.
(C)	Additional Staff. The program must ensure an overall staff-to-participant ratio of one to six
by hiring additional professional or paraprofessional staff from any of the disciplines listed in 130
CMR 417.421(B)(2) and (3).
417.422:  Organizational Structure
(A) Program Director.
(1)	A psychiatric day treatment program must designate a full-time professional as overall administrator and clinical director to be responsible for the program and charged with day-today responsibility over it.
(2)	If the psychiatric day treatment program has more than 22 participants but less than 28, the program director must not also provide over 10 hours a week of direct service.
(3)	The program director must have the following educational and work experience.
(a) Educational Requirements. A program director must have one of the following
college degrees:
(i) a master’s degree in one of the disciplines set forth in 130 CMR 417.421(B)(2)
and (3), except for occupational therapy and psychiatric nursing;
(ii) a master's degree in a related health field (such as health administration or public
health); or
(iii) a bachelor's degree in nursing (to become a registered nurse) or in occupational
therapy, unless the basic preparation took place at a master's degree level.

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(b) Experience Requirements. A program director must have five years of full-time, supervised clinical experience in a multidisciplinary team treatment setting, and a familiarity with the principles of the rehabilitation and recovery model. Two years of this experience must be attained after the degree required in 130 CMR 417.422(A)(3)(a) has been received, except for registered nurses and occupational therapists with a bachelor's degree who must have the required five years of experience subsequent to receiving their degrees. Occupational therapists with a bachelor's degree in occupational therapy and a master's degree in a related health field, as described in 130 CMR 417.422(A)(3)(a)(ii), must have two years of the below experience subsequent to receiving their master's degree. Experience should be broken down as follows:
(i) two years of work with a participant population similar to that receiving
psychiatric day treatment program services;
(ii) one year (which may be concurrent with one of the foregoing two years) in
another day treatment program; and
(iii) two years in an administrative/supervisory category. (4) The program director's responsibilities include:
(a)	hiring and firing of clinical staff;
(b)	overall supervision of staff performance;
(c)	establishing policies and procedures for participant treatment;
(d)	accountability for adequacy and appropriateness of participant treatment;
(e)	coordinating staff activities to meet program objectives;
(f)	program evaluation; and
(g)	establishing and supervising in-service training and education.
(B) Medical Director.
(1)	The psychiatric day treatment program must designate a psychiatrist who meets the qualifications outlined in 130 CMR 417.423(A) as the medical director. The medical director is responsible for establishing all medical policies and protocols and for supervising all medical services provided by the staff.
(2)	The role of the medical director in the program, apart from any other duties assumed under 130 CMR 417.422(B)(1), must include the following:

(a)	participation in the ongoing multidisciplinary evaluation and review of each participant’s status;
(b)	review of physical examination reports on all participants participating in the program;
(c)	prescription of any required medication in writing; and
(d)	coordination of all aspects of the participant’s treatment plan that involve physicians outside the program.

(3)	The medical director may be either a staff member or a consultant, but must work on site for a minimum of four hours a week. In addition, arrangements must be made so that the medical director or another psychiatrist is available for telephone consultations every day the program is open.
(4)	If the medical director is a member of the treatment team, his or her responsibilities must include active involvement in all aspects of treatment planning and service delivery.
(3)	
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417.423: Qualifications of Professional Staff
The Division does not certify a psychiatric day treatment program unless all its professional staff meet the qualifications for their respective disciplines set forth in 130 CMR 417.423(A) through (K), and can demonstrate a familiarity with the principles of rehabilitation and recovery. Any unlicensed member of the professional staff must receive weekly supervision from a licensed member of the clinical team. However, the Division may waive these requirements or those in 130 CMR 417.422 if the program demonstrates that meeting them will cause severe hardship, that its current staff members can competently perform assigned responsibilities, and that the overall quality of the program will not be compromised by the waiver.
(A)	Psychiatrist.
(1)	At least one psychiatrist employed by a psychiatric day treatment program, whether full time or as a consultant, must either currently be certified by the American Board of Psychiatry and Neurology, or be eligible and applying for such certification.
(2)	Any additional psychiatrists must be at least licensed physicians in their second year of a psychiatric residency program accredited by the Council on Medical Education of the American Medical Association. Such physicians must be under the direct supervision of a fully qualified psychiatrist.

(B)	Psychologist. Any psychologist employed at a psychiatric day treatment program must either be licensed by the Massachusetts Board of Registration of Psychologists, or have at least a master's degree in counseling psychology or clinical psychology from an accredited institution and one year of full-time supervised clinical experience in a mental health setting subsequent to receiving the master's degree.
(C)	Social Worker. A social worker employed at a psychiatric day treatment program must have a master's degree in social work and one year of postgraduate experience in a multidisciplinary mental health setting and must be licensed as an independent clinical social worker or eligible and in the process of applying for such licensure. Any additional social workers employed by the program must have a master's degree in social work.
(D)	Psychiatric Nurse/Clinical Specialist (RNCS). A psychiatric nurse/clinical specialist employed at a psychiatric day treatment program must have a master’s degree in nursing, be currently licensed to practice in the Commonwealth, and must be certified by the American Nurses Association as a clinical specialist in psychiatric nursing with RNCS designation. Any RNCS employed at a psychiatric day treatment program who is licensed to prescribe medications must make available to the Division evidence of authorization from the Commonwealth of Massachusetts Board of Registration in Nursing, a completed and accepted Massachusetts Controlled Substance Registration, and a current, valid, and unrestricted Drug Enforcement Agency certificate. Any RNCS must have one year of experience in a mental health setting.
(B)	
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(E)	Psychiatric Nurse. A psychiatric nurse employed at a psychiatric day treatment program must
have either a bachelor of science degree in nursing and one year of experience in a mental health
setting or its equivalent, or a license as a registered nurse and two years of experience in a mental
health setting.
(F)	Licensed Mental Health Counselor. A licensed mental health counselor employed at a
psychiatric day treatment program must have a master’s degree in the mental health field, one year
of postgraduate experience in a multidisciplinary mental health setting, and must be licensed as a
mental health counselor or eligible and in the process of applying for such licensure. Any
additional mental health counselors employed by the program must have a master’s degree in the
mental health field.
(G)	Rehabilitation Counselor. A rehabilitation counselor employed at a psychiatric day treatment
program must have a master's degree in rehabilitation counseling or vocational counseling and one
year of experience in a mental health setting. The rehabilitation counselor must be either certified
by the Council on Rehabilitation Education or eligible and applying for such certification.
(H) Expressive Therapist. An expressive therapist employed at a psychiatric day treatment program must have a master's degree from an accredited program in dance, movement, music, psychodrama, art, or intermodal expressive therapy, and one year of supervised experience in a mental health setting subsequent to that degree.
(I) Occupational Therapist. An occupational therapist employed at a psychiatric day treatment program must be currently registered with the American Occupational Therapy Association and must have at least two years of supervised post-registration experience in a multidisciplinary mental health setting.
(J) Allied Health Professionals. An allied health professional employed at a psychiatric day treatment program must have a bachelor's degree in a field related to mental health, such as psychology, social work, or counseling, from an accredited educational institution with no experience necessary.
(K) Paraprofessional Staff. A paraprofessional staff member employed at a psychiatric day treatment program must have at least two years of experience in a mental health program and must receive weekly supervision from a qualified professional in psychiatry, psychology, social work, psychiatric nursing, or occupational therapy.
(130 CMR 417.424 through 417.430 Reserved)

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417.431: Requirements for Admission
(A)	Applicants to a psychiatric day treatment program must be evaluated by a multidisciplinary team composed of the treatment team and a psychiatrist (if the psychiatrist is not a member of the treatment team) following the admission procedures set forth in 130 CMR 417.432. The multidisciplinary team may admit the applicant to the program only if it determines that the applicant has a mental illness and functional deficits appropriate to psychiatric day treatment. Documentary evidence must support these findings.
(B)	Applicants are considered appropriate for psychiatric day treatment program services if substantial functional limitations exist in at least two of the following areas:

(1)	emotional stability;
(2)	vocational/educational productivity;
(3)	social relations; and
(4)	self-care.
(C)	Applicants are not considered appropriate for psychiatric day treatment program services if
their primary diagnosis or functional characteristics include:
(1)	total dysfunction;
(2)	active alcohol, drug, or substance abuse to an extent that precludes benefit from the program;
(3)	a primary diagnosis of mental retardation;
(4)	imminent threat of suicidal or homicidal behavior;
(5)	inability to meet ordinary minimal demands of life;
(6)	unwillingness or inability to follow through with a therapeutic contract, whether verbal or written; or
(7)	absence of any potential to move into a less intensive level of care through psychiatric day treatment program services.
417.432: Admission Procedures
(A)	A qualified professional employed by the psychiatric day treatment program must conduct a comprehensive evaluation, including an admission interview, to evaluate the applicant's potential to benefit from the services of the program and document the applicant's functional level.
(B)	This comprehensive evaluation must be reviewed by the multidisciplinary team described in 130 CMR 417.431(A) including an examination of the applicant's medical status.
(C)	If the applicant is referred to the program by a mental health clinic, hospital, physician, or by a psychotherapist, the program must document their attempts to obtain reports of previous histories and evaluations from the referring institution or individual. If this preliminary evaluation indicates that admission is not appropriate, the program must notify the referring agency or individual of this and terminate the admission procedures. If the preliminary evaluation indicates that the applicant may benefit from psychiatric day treatment program services, the comprehensive evaluation set forth in 130 CMR 417.432(A) and (B) should then be completed.
(A)	
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(D)	If the comprehensive evaluation does not sufficiently demonstrate that the applicant needs or
has a functional level appropriate for psychiatric day treatment program services, the applicant
may be accepted as a participant on a trial basis to determine the ability of the program to meet the
applicant’s needs. The Division pays the program for services provided during such a therapeutic
trial period only under the following conditions:
(1)	the applicant’s record must contain specific documentation as to the need and time frame of the therapeutic trial period;
(2)	the trial period must not exceed two weeks; and
(3)	the multidisciplinary team must review and update the preadmission evaluation at the end of the therapeutic trial period.
(E)	If an applicant is not considered appropriate for psychiatric day treatment program services,
whether from the determinations of the comprehensive evaluation or from a therapeutic trial
period, the program must formulate alternative treatment referrals with the applicant and arrange
for such referrals within a 48-hour period from the time of the evaluation.
417.433: Treatment Planning
(A)	The multidisciplinary team described in 130 CMR 417.431(A) must prescribe a plan of therapeutic activities and treatment designed to improve the participant’s ability to function independently and thus to move into a less intensive level of care. This plan must be developed with and agreed to verbally or in writing by the participant. The multidisciplinary team must develop the plan after 10 participant visits to the program or by the end of the first month of attendance, whichever occurs first.
(B)	The treatment plan must be goal oriented, focused on the principles of rehabilitation and recovery, and time frames must be established for the attainment of short- and long-term behavioral goals. The treatment plan must be designed with an understanding of the individual in the context of the home or living situation. This may be achieved through home visits or family meetings.
(C)	All elements of the treatment plan must be documented in the medical record, as set forth in 130 CMR 417.437.
(A)	
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417.434: Home Visits
One of the professional staff may visit the member’s residence, unless this visit is clinically contraindicated with the reasons for this documented in the member’s record. If a home visit is conducted, that home visit must include evaluation of family and peer interaction, the condition of the home, and any details specific to the member’s case. A report of this visit must be inserted in the member’s record. Further visits must be conducted if the need is indicated during treatment and documented in the member’s record.
417.435: Case Management
(A)	A member of the program's professional or paraprofessional staff must be assigned to each member as case coordinator to assume primary responsibility for that member’s case. The case coordinator supervises the implementation of the treatment plan, maintains the member’s records, initiates periodic review of the treatment plan for necessary modifications or adjustments, coordinates the various services provided by the program itself and by other agencies, coordinates referrals to other state agencies as needed, meets regularly with relatives and significant friends of the member, and monitors the member’s progress in accomplishing the treatment goals.
(B)	The case coordinator must review the member’s treatment goals and level of functioning weekly and, during staff meetings, inform the staff of any significant changes in the member’s medical, mental, or emotional status. The entire staff must review the member’s overall progress every 60-calendar days and, with the participation of the member, alter or revise the treatment plan as necessary.
(C)	If the member fails to keep appointments or to adequately participate in the treatment plan, the case coordinator must make every effort to encourage the member to do so, and these follow-up efforts must be documented in the member’s record.
417.436: Discharge from Program
A member must be discharged from a psychiatric day treatment program when a periodic review shows that the member has met all therapeutic goals or has ceased to substantially benefit from the program. If this discharge occurs because the member requires a lesser level of services than those of psychiatric day care, the program must prepare the member as much as possible for the transition to a less intensive program or environment, such as a social club, a mental health clinic, or a social services agency.

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417.437: Recordkeeping Requirements
(A)	A psychiatric day treatment program must maintain on its premises the original records for each member for a period of at least six years following the date of service.
(B)	Before providing services, the program must obtain written authorization from each member or from the member’s legal guardian to release information obtained by the program to program staff, federal and state regulatory agencies, and, when applicable, to referral providers, to the extent necessary to carry out the purpose of the program and to meet regulatory requirements. All such information must be released on a confidential basis.
(C)	The records must be complete, accurate, and properly organized.
(D)	In community health centers and hospitals, the psychiatric day treatment records must be integrated with the member’s overall records.
(E)	The member’s record must include at least the following information:
(1)	all identifying data;
(2)	a report of an examination performed by a physician within six months of the time of admission. If no such current examination exists, one must be performed within 30 days after the member’s request for services. It is the responsibility of the psychiatric day treatment case coordinator to ensure that arrangements are made for such an exam. If the member resists the examination, the member’s record must document the reasons for postponement;
(3)	the name and address of the member’s primary physician or medical clinic. The program must locate a physician or medical clinic for the member if the member is currently without one;
(4)	a description of the member’s psychiatric condition as indicated by the member and others, including the referral source, if any;
(5)	the events that precipitated the member’s referral;
(6)	a comprehensive statement of the member’s physical, psychosocial, social, economic, educational, and vocational assets and disabilities, stated in terms of the functional capacities of the member and summarized in a rating of the member’s functional level;
(7)	the clinical impression and formulation, including diagnosis;
(8)	short- and long-range goals that are realistic and obtainable, and a time frame for their achievement;
(9)	a schedule of activities and therapies, both in and out of the program, necessary to achieve the member’s goals and the responsibilities of each member of the treatment team;

(10)	the prescribed schedule for attendance and a record of the member’s actual attendance;
(11)	a schedule of review dates to occur no less than once a month to reassess the member’s progress in accomplishing goals and increasing the member’s functional level;
(12)	a written record of the reassessments required in 130 CMR 417.437(E)(11) that includes recommendations for revision of the treatment plan, when indicated, and the names of the reviewers;
(10)	
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(13)	the name of the case coordinator;
(14)	weekly notes by the case coordinator as well as notes by the staff physician and other staff members significantly involved in the treatment plan;
(15)	reports on all conferences with family, friends, and outside professionals;
(16)	appraisal of the need for a home visit and the findings of any home visit;
(17)	all information and correspondence to and from other involved agencies, including appropriately signed and dated consent forms;
(18)	a drug-use profile (both prescribed and other); and
(19)	when discharged, a discharge summary, including a recapitulation of the member’s treatment, a brief summary of the member’s condition and functional level on discharge, recommendations for appropriate services that should be provided in subsequent programs by the same or other agencies to accomplish the member’s long-range treatment goals, and the program's future responsibility for the member’s care.
417.438: Written Policies and Procedures
A psychiatric day treatment program must have and observe written policies and procedures that include:
(A)	a statement of program philosophy and objectives;
(B)	admission procedures, including criteria and procedures for multidisciplinary review of each individual referral;
(C)	treatment procedures, including development of the treatment plan, case assignment, home visit, periodic review, and follow-up on drop-outs;
(D)	discharge criteria and procedures;
(E)	medication policy;
(F)	referral policy, including procedures for ensuring uninterrupted and coordinated patient care
upon transfer;
(G)	procedures for clinical emergencies that occur both during and outside the program's
operating hours;
(H) recordkeeping policy;
(I) personnel and management policies, including policies for hiring, discharging, and supervising staff;

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(J) a policy for proper food preparation, cleanliness, and storage, including designation of a staff person to take responsibility for supervision of the member’s food preparation at each meal;
(K) explicit fee policies for billing third-party payers and patients, along with procedures for cancellation and fee reductions; and
(L) procedures for fire and other nonclinical emergencies.
417.439: Administration
(A)	Organization. The program must establish an organization table showing major operating programs of the facility, with staff divisions, administrative personnel in charge of each program, and their lines of authority, responsibility, and communication.
(B)	Staff Meetings. The program must document that staff meetings are held at least once a month to review the program and to recommend appropriate changes, if any.
(C)	Staff Development.

(1)	Each staff member must receive supervision appropriate to the person's skills and level of professional development. Supervision must occur within the context of a formalized relationship that provides frequent and regularly scheduled individual or group personal contact with the supervisor.
(2)	The psychiatric day treatment program must establish and follow procedures for staff training and evaluation.
417.440: Service Limitations
(A)	Length of Sessions. The Division pays a psychiatric day treatment program per hour of treatment.
(B)	Individual Therapy or Medication Evaluation. The Division pays a psychiatric day treatment program certified to provide mental health center services for individual therapy or a medication evaluation as a separate service only when it is not provided during a psychiatric day treatment program session. The provider must specifically indicate in the member’s record the circumstances that necessitated individual therapy in addition to psychiatric day treatment program services. However, the Division does not pay for group therapy provided separately to a member receiving psychiatric day treatment program services.
(A)	
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(C) Other Reimbursable Services. The Division pays a psychiatric day treatment program for the following services only when such services are not provided during a psychiatric day treatment program session:
(1)	a preadmission evaluation visit of at least one hour that consists of a comprehensive evaluation to determine the need for psychiatric day treatment program services and to design a treatment plan;
(2)	a home visit of at least one hour that consists of direct evaluation or treatment provided to the member in the member’s residence; and
(3)	a face-to-face individual or group session lasting at least one hour with the member’s family or other involved persons to interpret accumulated data and to advise them on how to assist the member.
REGULATORY AUTHORITY
130 CMR 417.000: M.G.L. c. 118E, §§ 7 and 12.

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601 Service Codes and Descriptions
Service
Code	Service Description
H2012	Behavioral health day treatment, per hour
H2012-U1      Behavioral health day treatment, per hour; preadmission evaluation visit
90887	Interpretation or explanation of results of psychiatric, other medical examinations and
procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient

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