N.J. Admin. Code § 10:54-2.12

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:54-2.12 - Minimum documentation; mental health services

(a) For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following:

1. The specific services rendered and modality used, for example, individual, group, and/or family therapy;

2. The date and the time services were rendered;

3. The duration of services provided, for example, one hour, or one-half hour;

4. The signature of the physician who rendered the service;

5. The setting in which services were rendered;

6. A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care;

7. Notations of progress, impediments, treatment, or complications; and

8. Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis.

(b) Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient's medical record, as well as any other information important to the clinical picture, therapy, and prognosis.

(c) For mental health services that are not specifically included in the patient's treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Utilization Management, Mental Health Services, Mail Code #18, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient's plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.

N.J. Admin. Code § 10:54-2.12

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 New Jersey Register 3929(a), 33 New Jersey Register 555(a).
In (c), substituted "Utilization Management" for "Health Services Administration" preceding ", Mental Health Services".