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Guidance on New York State OMH 14 NYCRR Part 590 establishing standards, services, and operational expectations for Comprehensive Psychiatric Emergency Programs (CPEPs); intended for CPEP providers and planners implementing program and billing requirements in NYS.
Key ActionEnsure triage or full emergency visits are initiated within six hours of receipt into the CPEP and document required assessments, treatment plans, and discharge planning.
No material clinical or coverage changes in this revision.
24/7Psychiatric emergency services and Extended Observation Beds operational expectation
≤6hTriage/referral and full emergency visit initiation timeframe
72hMaximum EOB duration
7 days/week
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Crisis outreach minimum availability
14 daysFollow-up services billing window
Coverage Criteria
inv-01: Triage and Referral — Covered when ALL criteria met
Triage and referral services are appropriate when ALL of the following apply:
Triage and Referral Criteria: Face-to-face in-person evaluation by a staff physician or psychiatric nurse practitioner (other disciplines may assist).
Performs psychiatric diagnostic examination; may include basic health screening, risk assessments, discharge planning and linkage to community services.
Registration/Receipt: Individual has been received into the CPEP and a record/registration has been completed (clock for timeframes begins at receipt).
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Timing: Services are initiated as soon as possible and in any event within six hours after the individual is received into the CPEP emergency room.<=6 hours
Service components: May include psychiatric diagnostic examination, basic health screening/vitals, risk assessments (suicide/violence), collateral communication, and development of a discharge plan or initiation of full emergency visit when indicated.
May result in discharge or escalation to a full emergency visit.
inv-02: Full Emergency Visit — Covered when ALL criteria met
Full emergency visit services are appropriate when ALL of the following apply:
Full Emergency Visit Criteria: Face-to-face in-person evaluation by a psychiatrist (with team support as needed).
Other clinical staff may assist in assessment and treatment.
Serious presenting symptoms: Presenting symptoms are serious and have potential to substantially impact safety to self or others or ability to care for self in the community.
Serious presentations include EMS or law enforcement transport, involuntary presentations, or need for de-escalation/crisis intervention.
Immediate treatment/evaluation needed: Determination that treatment should begin immediately and/or evaluation for EOB admission or inpatient admission is required.
Timing: Initiated as soon as possible and in any event within six hours after the individual is received into the CPEP emergency room.
inv-03: EOB Admission — Covered when ALL criteria met
Extended Observation Bed (EOB) admission is appropriate when ALL of the following apply:
EOB Admission Criteria: Examining physician determines the individual requires extensive evaluation, observation, assessment, or stabilization of acute psychiatric symptoms for up to 72 hours.<=72 hours
72-hour period begins when the individual is received into the CPEP (registration completed).
Receipt and documentation: Individual has been received into the CPEP (registration completed and record created) and rationale for EOB placement is documented in the case record.
Daily written documentation of need for continued retention required for stays up to 72 hours; nursing assessment each shift; minimum daily psychiatric assessment.
Clinical purposes for EOB: EOB may be used for gathering collateral/longitudinal observation, metabolism/treatment of substances, coordination with family/outpatient providers, therapeutic programming, and discharge planning.
Safety plans required for individuals at moderate-high risk of harm.
inv-04: Crisis Outreach and Follow-Up — Covered when ANY criteria met
Crisis Outreach Services (including Mobile Crisis and Follow-Up) are appropriate when ANY of the following apply:
Community crisis presentation: Individuals in the community exhibiting symptoms of mental illness and/or acute stress that significantly impair coping capacity or present risk for escalation that cannot be managed without intervention.
Mobile Crisis Outreach is voluntary and provided in the community.
High-risk or disconnected individuals: Individuals identified at discharge from CPEP or by Mobile Crisis teams who are high risk or disconnected from care and need follow-up linkage or stabilization.
Crisis Outreach Follow Up is not provided to individuals being discharged from psychiatric inpatient units.
Need for linkage/safety planning/medication: Need for linkage to community services, safety planning, initiation/management of medications for psychiatric symptoms or substance use/withdrawal, or other stabilization activities.
Crisis outreach may include medication when appropriate.
inv-05: Admissions, Evaluation, Observation, and Retention
Covered when clinical criteria and procedures below are followed
CPEP Admission: Staff physician (preferably psychiatrist) determines the person may have a mental illness or co-occurring disorder requiring immediate observation, care and treatment in a CPEP and likely to result in serious harm to self or others; complete OMH Form 476 front page and provide notice of status and rights.
Triage vs Full Evaluation: If triage clinician determines a full evaluation is needed, proceed to a full emergency visit; only one of triage and referral or full evaluation may be billed in a single CPEP episode of care.per episode
Full Emergency Visit timing: An individual must be examined by a staff psychiatrist as soon as practicable and in any event no later than six hours after receipt into the CPEP.<=6 hours
inv-06: Crisis Outreach and Peer Services
Crisis outreach and peer services requirements
Crisis Outreach Services: Provide therapeutic communication, coordination with supports, psychiatric consultation, safety planning, referral/linkage, peer services, and medications when appropriate to support stabilization and linkage to care.
May be provided by the CPEP or through an approved contracted provider.
Availability and staffing: Crisis outreach must be provided seven days per week during at least day and evening hours; when providing outreach in the community at least two crisis outreach staff must be present, one of whom is a licensed professional; inclusion of certified peer specialists strongly recommended.7 days/week (day and evening); minimum 2 staff including 1 licensed professional
Peer Services Requirements: Peer support services must be available within the CPEP and connections to community peer programs required; CPEPs must post notices of on-site and local off-site peer counseling/self-help services and contact information.
inv-07: Assessment, Examination, Formulation, and Discharge Planning
Clinical evaluation and discharge planning requirements
Information Gathering: Obtain history from PSYCKES, local EHRs, RHIO/QE and other databases; identify prior providers, AOT orders, prior medication use, substance use history, medical issues, and contact family/collaterals with efforts available 24/7.
Screening and Assessment: Assess primary language needs, screen for alcohol/substance use, assess suicidality/homicidality and risk for violence, assess social determinants, and use standardized evidence-based screening tools as appropriate.
Examination: When indicated perform mental status exam, medical exam (past medical history, review of systems, meds/allergies, vitals), targeted physical exam, and order labs/diagnostics as needed.
Formulation and Treatment Plan: Create a formulation including presenting complaints, crisis description, differential diagnosis and risk assessment; develop a comprehensive psychiatric emergency treatment plan with disposition decision and interventions (safety planning, collateral follow-up, medication plans).
inv-08: CPEP admission, EOB admission, retention, and transfer criteria
Covered when the following legal/clinical timing and standards are met:
Emergency examination timeline: A staff physician (preferably psychiatrist) must examine and determine the individual meets the CPEP emergency standard within six hours after being received in the CPEP emergency room.6 hours
EOB involuntary admission confirmation: To admit involuntarily to an EOB, a staff psychiatrist must, within 24 hours after receipt, examine the individual and confirm the initial physician's finding that the individual meets the emergency standard and would benefit from extended observation and treatment.24 hours
EOB retention duration: Individuals admitted to EOB may continue stay up to 72 hours from admission to the CPEP, after which they must be discharged, transferred, or evaluated for inpatient admission under MHL 9.39/9.27.72 hours
inv-09: Discharge planning and follow-up criteria
Discharge from CPEP/EOB is allowed when discharge planning and follow-up linkage requirements are met:
Discharge planning components: Complete discharge instructions prior to discharge including summary of findings, treatment recommendations, pending labs and result plans, medication reconciliation and prescriptions, peer services information, follow-up appointment date/time/contact, provider contacts, and wellness and safety plan; involve the individual in planning.
Comprehensive discharge summary: For Full Emergency visits and EOB stays, complete a comprehensive discharge summary within five days including hospital course, collateral involvement, labs/imaging results, condition at discharge (mental status and risk assessment), and discharge diagnosis; provide copy to relevant providers.5 days
Follow-up verification: Verify after-care appointment attendance via EHR/RHIO/QE or direct contact; if confirmation fails, perform reasonable outreach and offer alternative resources/referrals as needed.
Develop risk-based protocols to determine who receives follow-up.
inv-10: Covered services and criteria
Covered CPEP services and documentation requirements
Per-day service limitation: An individual may receive one triage and referral visit or one full emergency visit per calendar day; a provider may also be reimbursed for one crisis outreach service plus either one triage/referral or one full emergency visit per calendar day.per calendar day
If both triage and full emergency visit occur the same day, reimbursement is for the full emergency visit.
Full emergency visit components: Full emergency visits must include psychiatric/mental health diagnostic examination, psychosocial assessment, medical examination, comprehensive psychiatric emergency treatment plan and discharge plan.clinical need
EOB documentation and billing conditions: EOB placement requires documented rationale in the case record; daily written documentation of need for continued retention is required for stays up to 72 hours; no involuntary retention in CPEP beyond 24 hours unless admitted to an EOB.
inv-10: Covered Services
Covered CPEP services and conditions for billing
Basic per-day billing rule: An individual may receive one triage and referral visit (4007) or one full emergency visit (4008) per calendar day; if both are provided, reimbursement is for the full emergency visit. Separate claims must be submitted for each rate code when multiple services are provided in a day.per calendar day
Providers must submit one claim per rate code per service per day.
Extended observation bed billing: Extended observation bed rate (4049) may be claimed only when a person has been held in the CPEP for more than 24 hours; extended observation claims are submitted for each subsequent calendar day up to 72 hours from initial arrival. If admitted to an inpatient unit, inpatient rate is claimed beginning on admission.>24 to <=72 hours
Admission to EOB is billed starting the calendar day after the visit was completed.
inv-12: Follow-up Services
Follow-up services under Medicaid Managed Care Crisis Intervention Benefit
Follow-up services reimbursement: CPEPs approved under the Medicaid Managed Care Crisis Intervention Benefit may bill Medicaid Managed Care Organizations for mobile and telephonic follow-up services provided within 14 days of a qualifying crisis episode.within 14 days
Follow-up services may be face-to-face or telephonic and include therapeutic communication, care coordination, linkage, referral, engagement, and contact with supports or providers.
Crisis outreach follow-up is explicitly described as a transitional service and should not replace ongoing outpatient treatment. Providers must make person-centered determinations about duration and intensity of follow-up so that services support linkage and engagement with community providers rather than serving as a substitute for continuing outpatient care.
This restriction also applies when follow-up is provided after discharge from emergency services: crisis outreach is intended to bridge to ongoing care and is not a permanent alternative to established community-based treatment.
Crisis outreach services are intended to be time-limited and transitional; the policy states that crisis outreach services should not take the place of ongoing treatment and support services in the community. Use of outreach should focus on assessment, safety planning, stabilization, and linkage to longer-term supports rather than substituting for established outpatient providers or care plans.
Effective October 7, 2020, CPEPs are no longer required to provide Crisis Residence services under Part 590. The guidance directs CPEPs to develop close linkages with Crisis Residential programs established under OMH Part 589 and to refer appropriate individuals to those programs as clinically indicated and consistent with patient preference.
Crisis Residence services referenced in the rule have been moved out of Part 590; instead, Crisis Residence programs are addressed under OMH Part 589. CPEPs should therefore refer individuals to Part 589 Crisis Residential programs when clinically appropriate and build collaborative relationships with local crisis residences to support transitions of care.
If an individual admitted to an extended observation bed (EOB) is subsequently transferred to a psychiatric inpatient unit, the EOB rate must not be claimed. The psychiatric inpatient unit rate is claimed beginning on admission to the inpatient unit, and EOB billing applies only to the calendar days the patient was held in observation per the EOB billing rules.
Billing a triage and referral visit requires that the individual present with symptoms of a behavioral health crisis. Visits motivated solely by social needs (for example, assistance with food, housing, or social interaction) do not meet the definition for a billable triage/referral unless the individual is also exhibiting behavioral health crisis symptoms that require the triage/referral level of service.
The policy does not present standalone "not medically necessary" declarations for named services; rather, billing is governed by per-day visit rules and extended observation bed (EOB) billing criteria. Specifically, only one triage and referral (4007) or one full emergency visit (4008) is reimbursable per individual per calendar day (with the full emergency visit reimbursed if both occur), and the EOB rate (4049) may only be claimed when the individual has been held in the CPEP for more than 24 hours and up to 72 hours.
Coding and Timeframe Rules
Referenced admission/legal status codesmixed
9.13
Inpatient admission code referenced for conversion from CPEP/EOB when criteria met
9.39
Inpatient admission code referenced for conversion from CPEP/EOB when criteria met
9.27
Inpatient admission code referenced for conversion from CPEP/EOB when criteria met
CPEP rate/procedure codesmixed
4007
Triage and Referral visit
4008
Full Emergency Visit
CPEP rate/procedure codes — coveredmixedCovered
4007
Triage and Referral visit
4008
Full Emergency Visit
4009
Crisis Outreach Service
4049
Extended Observation Bed
inv-23: Time thresholds — triage/referral and Full Emergency Visit initiation timeframe and EOB duration
Triage/Full Visit initiationMust be initiated as soon as possible and in any event within 6 hours after the individual is received into the CPEP
EOB maximum durationUp to 72 hours from time the individual is received in the CPEP
EOB billing triggerExtended observation bed rate may only be claimed when a person has been held in the CPEP for more than 24 hours
Per-day visit limitOne triage and referral (4007) OR one full emergency visit (4008) reimbursable per individual per calendar day
inv-24: CPEP Full Exam Timeframe — psychiatrist exam within 6 hours
Provider Actions, Billing & Documentation
Prior Authorization
Prior authorization — not specified
No prior authorization requirements for CPEP, triage/referral, full emergency visits, or extended observation bed services are specified in this guidance excerpt.
Prior Authorization
No prior authorization language in this section
There is no prior authorization language present in the policy excerpts for CPEP services; billing is described in the Billing section but no PA process is defined here.
Billing Rule
Background
Comprehensive Psychiatric Emergency Programs (CPEPs) deliver triage, observation, evaluation, treatment and referral for individuals with known or suspected mental illness who present in crisis. Services include a face-to-face triage and referral visit (rate code 4007) for quick stabilization or discharge planning, a more in-depth full emergency visit (rate code 4008) for serious presentations requiring immediate treatment or evaluation for extended observation or inpatient admission, and, when applicable, placement in an Extended Observation Bed (EOB) with specific billing rules. CPEPs must register each individual on receipt, initiate triage or full evaluation promptly (generally within 6 hours), and document assessments, treatment plans and discharge/linkage activities in the case record.
Definitions
inv-50: Extended Observation Bed (EOB) definition
DefinitionExtended Observation Bed (EOB) is a bed located in or adjacent to the CPEP emergency room providing a safe environment for individuals requiring extensive evaluation, observation, assessment, or stabilization of acute psychiatric symptoms
DurationProvides care for a period up to 72 hours, calculated from time received into the CPEP
PurposeUsed for gathering collateral information, metabolism of substances, treatment of intoxication/withdrawal, coordination with family/outpatient providers, and discharge planning
inv-51: Triage and Referral Services definition
DefinitionTriage and referral: face-to-face in-person interaction between an individual and a staff physician or psychiatric nurse practitioner to determine the scope of emergency service required; includes psychiatric diagnostic examination and may result in discharge or further evaluation
Level-of-Care Criteria
inv-63: CPEP Emergency Room / Extended Observation Bed
CPEP Emergency Room / EOB Admission: Individuals received into CPEP via referral, EMS, police, or walk-in; registration completed (record created); triage determines need for full emergency visit or EOB admission.
Observation levels and staffing must support care and safety.
EOB Continued Stay: Observation levels determined by treatment team; nursing assessments each shift; minimum daily psychiatric assessment; safety plans for moderate-high risk; meetings and therapeutic programming as clinically indicated; total stay not to exceed 72 hours unless criteria for inpatient admission met.<=72 hours
Daily documentation of need for continued retention required.
Modalities Available: Psychiatric diagnostic examinations, medical examinations, psychosocial assessments, pharmacologic treatment (including for substance use/withdrawal), individual/family/group therapy, peer support, substance use evaluations by CASAC, activity/creative arts therapy, and safety planning.
inv-69: Telehealth
Telehealth is allowed in CPEPs with proper approvals and in accordance with OMH telehealth guidance; telephonic follow-up may be reimbursed under specific Medicaid Managed Care provisions.
See OMH telehealth guidance link for implementation details.
inv-70: CPEP treatment planning and interventions
Treatment plan content:
Visit Limits and Duration
inv-72: Crisis outreach follow-up — no fixed numerical cap
No fixed numerical capOMH removed a prior limit; crisis outreach follow-up has no preset numerical cap
Transitional natureServices are transitional and should not replace ongoing outpatient treatment
Person-centered durationProviders should make person-centered determinations for how long follow-up is provided to allow linkage to services
Duration decisionDuration of crisis outreach follow-up is determined on a person-centered basis to allow linkage to and engagement with services after crisis
No preset limitOMH expects appropriate, individualized determinations rather than a set time limit
Key ActionEnsure triage or full emergency visits are initiated within six hours of receipt into the CPEP and document required assessments, treatment plans, and discharge planning.
Service components: Includes psychiatric/mental health diagnostic examination, psychosocial assessment, medical examination, comprehensive psychiatric emergency treatment plan and discharge planning.
May result in EOB admission, inpatient admission, or community discharge.
Support transition to ongoing services: When follow-up services are needed to support transition to and engagement with ongoing community services after a crisis or discharge from CPEP.
OMH removed prior duration limit; follow-up duration is person-centered and transitional in nature.
Availability requirement: Crisis outreach must be provided seven days per week during at least day and evening hours; programs may plan further availability with local government units.7 days/week (day and evening)
Telephonic mobile crisis follow-up may be reimbursed for Medicaid Managed Care enrollees under the 1115 benefit.
Reassessment interval: An individual may be retained for no more than 24 hours before reevaluation by a staff psychiatrist; following reassessment may be discharged or admitted to an EOB if needed.<=24 hours before reevaluation
EOB Admission and duration: An individual may spend up to 72 hours in an EOB, calculated from time received in the CPEP (registration completed).<=72 hours
Involuntary retention: To retain an individual over objection an involuntary legal status must be in place (per Mental Hygiene Law Sec. 9.13 and related sections).
Follow-up duration guidance: OMH expects person-centered determinations for length of crisis outreach follow-up; there is no preset numerical limit and services are transitional in nature.
Crisis outreach should not replace ongoing outpatient treatment.
Treatment plans may be documented by psychiatrist or psychiatric nurse practitioner where appropriate.
Wellness and Safety Plan: Prepare and share Wellness and Safety Plans (suicide prevention, relapse prevention, WRAP, psychiatric advance directives) and attach to discharge plan when applicable.
Use PSYCKES to upload/access plans when available.
Ongoing assessment must verify continued meeting of emergency requirements.
Inpatient transfer / involuntary retention: An individual may be held involuntarily and transferred to inpatient services if they meet involuntary or emergency standards (§9.27 or §9.39); CPEP retention should not exceed 24 hours unless admitted to an EOB.24 hours unless EOB
up to 72 hours
Daily nursing assessments each shift and minimum daily psychiatric assessments required.
Psychiatrist exam timeframe
A staff psychiatrist must examine the individual as soon as practicable and no later than 6 hours after the person is received in the CPEP emergency room
Full visit initiationFull emergency visit must be initiated as soon as possible and within six hours of being received into the CPEP
Full visit componentsIncludes psychiatric diagnostic exam, psychosocial assessment, medical exam, comprehensive emergency treatment plan and discharge plan
inv-25: Reevaluation Interval — no more than 24 hours before psychiatrist reevaluation
Reevaluation intervalAn individual may be retained for no more than 24 hours before they are to be reevaluated by a staff psychiatrist
Post-reevaluation actionsFollowing reassessment the individual may be discharged or admitted to an EOB if further observation is needed
Documentation formIf admitted to EOB after reassessment, complete back page of OMH Form 476
inv-26: EOB Duration — up to 72 hours from time received in CPEP
EOB duration from receipt72 hours begins when the individual is received into the CPEP (completed registration and record created)
EOB retention limitRetention in an extended observation bed shall not exceed 72 hours (voluntary or involuntary)
Claiming windowClaims for the extended observation bed are submitted for each subsequent calendar day up to 72 hours from initial arrival
inv-27: Extended Observation Bed documentation frequency — daily documentation up to 72 hours
Documentation frequencyDaily written documentation of the need for continued retention must be included for those receiving EOB services up to 72 hours
Nursing assessmentsNursing assessment is performed by an RN every shift during EOB stays
Psychiatric assessment frequencyMinimum daily psychiatric assessment performed by the attending psychiatrist or a nurse practitioner under supervision
inv-28: Extended observation bed retention — >24 hours and up to 72 hours
EOB billing retention thresholdExtended observation bed rate may only be claimed when a person has been held in the CPEP for more than 24 hours (claims submitted for subsequent calendar days up to 72 hours)
Retention windowGreater than 24 hours and up to 72 hours for EOB retention (voluntary or involuntary)
Inpatient admission effectIf admitted to inpatient unit, the EOB rate is not claimed; inpatient rate applies beginning on admission
Follow-up services billing eligibility to MMCOs
CPEPs approved under the Medicaid Managed Care Crisis Intervention Benefit may bill Medicaid Managed Care Organizations for mobile and telephonic follow-up services provided to recipients of a qualifying crisis service.
Follow-up services eligible for reimbursement if provided within 14 days of qualifying crisis episode (see Billing).
Follow-up may be mobile (face-to-face) or telephonic and include therapeutic communication, care coordination, linkage, and engagement activities.
CPEP services are claimed on a daily basis using specific rate/procedure codes; triage and referral (4007), full emergency visit (4008), crisis outreach (e.g., 4009), and extended observation bed (4049) must be billed per the rate code for each calendar day the service applies.
Submit one claim per rate code for each distinct service provided on a calendar day.
Triage and Referral visit = 4007; Full Emergency Visit = 4008; Extended Observation Bed = 4049 (claimed for subsequent calendar days after >24 hours).
Billing Rule
Follow-up services billing guidance to MMCOs
CPEPs approved under the Medicaid Managed Care Crisis Intervention Benefit may bill MMCOs for mobile and telephonic follow-up services provided within 14 days of a qualifying crisis episode; these follow-up services can be face-to-face or telephonic and include therapeutic communication, coordination and linkage activities.
Follow-up services must occur within 14 days of the qualifying crisis to be eligible for MMCO billing.
Activities eligible include therapeutic communication, facilitation of engagement in outpatient services, care coordination, and referrals.
Step Therapy
Step therapy / sequencing — not applicable
No step-therapy or medication sequencing rules are specified; medication management during crisis outreach or CPEP treatment should be provided as clinically indicated.
Prescribe medications for psychiatric symptoms or substance use/withdrawal when appropriate during crisis outreach or CPEP treatment.
No formal step-therapy protocols are described in this excerpt.
Step Therapy
Step therapy — none specified
No formal step-therapy rules are described in this section of the guidance.
Documentation Required
Mandatory discharge planning steps
Before discharge clinicians must perform planned discharge activities including reviewing prior services, asking patient preferences, checking insurance compatibility, arranging referrals and prescriptions, coordinating with case managers/teams, and providing discharge instructions and wellness/safety plans.
Identify prior services and ask individual’s preference for post-discharge services.
Check insurance compatibility and contact insurer if needed.
Provide prescriptions or medication supply and schedule follow-up appointments.
Provide written discharge instructions and Wellness and Safety Plan and ensure individual participation.
Refer to crisis outreach, Health Home care manager or community supports as appropriate.
Documentation Required
Required clinical & administrative documentation
Providers must create a case record upon receipt into the CPEP (registration completed) and document triage/referral or full emergency visit activities, psychiatric diagnostic exams, psychosocial and medical assessments, treatment and discharge plans; for EOB admissions include safety plans and daily documentation for continued retention.
Create a record at receipt (registration completed) and include presentation note and identifying information.
Document psychiatric/medical history, social history, assessment findings, progress notes, medication orders, and attempts to contact collaterals.
For EOB: document rationale for placement and daily written justification of need for continued retention up to 72 hours.
Documentation Required
Admission & documentation requirements (OMH Form 476, rights)
Complete required admission forms: front page of OMH Form 476 for CPEP admission and the back page when admitting to an EOB; provide notice of status and rights and document brief exams if individuals request to leave before full assessment.
Complete OMH Form 476 front page on CPEP admission and provide notice of status and rights.
If admitted to EOB, complete the back page of OMH Form 476.
Document interactions and brief examinations when patients request to leave prior to full assessment.
Documentation Required
Discharge documentation requirements — instructions and 5-day summary
Discharge instructions must be completed prior to every discharge and included in the case record; comprehensive discharge summaries for Full Emergency visits and EOB stays must be completed within five days and include hospital course, collateral involvement, pending results, condition at discharge, and discharge diagnosis.
Discharge instructions: summary of findings, treatment recommendations, pending labs, medication reconciliation, prescriptions, peer services info, and follow-up appointment details.
Comprehensive discharge summary: hospital course, collateral involvement, lab/imaging results, condition at discharge (mental status and risk), and discharge diagnosis — completed within five days.
Documentation Required
Case record & EOB documentation requirements
Maintain a complete, legible case record including presentation note, identifying information, psychiatric/medical history, social history, referral source, assessments, progress notes, dated medication orders, documentation of collateral contact attempts, and for EOB stays the rationale for placement plus daily documentation of need for continued retention.
Case record must include presentation note with presenting problem, care required, and attempts to contact collaterals.
Include reports of diagnostic exams, assessments, consultations, progress notes, and signed medication orders.
For EOB: include rationale for placement and daily written documentation supporting continued retention up to 72 hours.
Billing Rule
Claiming & documentation for visits and extended observation
Document the calendar day of the triage/referral or full visit (submit day-visit claim for that day) and submit extended observation bed claims for each subsequent calendar day when the individual is held >24 hours and up to 72 hours from initial arrival.
Triage/referral or full visit claim submitted for calendar day the visit is completed.
EOB rate may only be claimed when held more than 24 hours; submit EOB claims for each subsequent calendar day up to 72 hours.
If inpatient admission occurs, inpatient rate is claimed instead beginning on admission.
Triage and referral and full emergency visit services must be initiated as soon as possible and in any event within six hours after an individual is received into the CPEP; Extended Observation Bed stays are limited to up to 72 hours (calculated from time received).
Initiate triage/referral or full emergency visit within 6 hours of receipt into the CPEP.
EOB duration limited to up to 72 hours from time received (received = registration completed and record created).
Billing Rule
Single billable CPEP service per episode — bill one visit type
Only one CPEP service — either a triage and referral visit or a full emergency visit — may be billed in a single CPEP episode of care; if both occur in the same calendar day reimbursement is for the full emergency visit.
If both a triage/referral and a full emergency visit occur the same day, reimbursement will be for the full emergency visit.
Providers must ensure billing reflects a single billed visit type per episode to avoid claim denial.
Note
Retention over individual's objection requires involuntary legal status
An individual may not be retained in a CPEP over their objection unless an involuntary legal status is in place; lack of such status precludes involuntary retention.
To retain a person over objection, an involuntary legal status must be established per Mental Hygiene Law references.
No involuntary retention in CPEP beyond 24 hours unless admitted to an EOB with appropriate legal/clinical procedure.
Billing Rule
Billing service limits & claim submission — separate claims per service, reimbursement limits apply
If multiple CPEP services are provided in one day, submit separate claims—one per rate code—for each distinct service; however reimbursement is limited to one triage/referral or one full emergency visit per individual per calendar day (full emergency visit supersedes triage).
Submit one claim per rate code for each service provided on the same calendar day.
Reimbursement rules limit payment to one triage (4007) OR one full emergency visit (4008) per individual per calendar day; crisis outreach may also be reimbursed in addition.
Billing Rule
Per-day visit claim limits — one visit reimbursable per day
Reimbursement is restricted to one triage and referral visit (4007) OR one full emergency visit (4008) per individual per calendar day; providers must follow calendar-day claim limits to avoid improper billing.
One reimbursable triage/referral (4007) or full emergency visit (4008) per individual per calendar day.
If both visit types occur, payment is for the full emergency visit only.
Timing
Initiated as soon as possible and within six hours after an individual is received into the CPEP
Billing codeRate/procedure code: 4007 (Triage and Referral visit)
inv-52: Full Emergency Visit definition
DefinitionFull Emergency Visit: an in-depth face-to-face evaluation performed by a psychiatrist (with team support) including psychiatric diagnostic exam, psychosocial and medical assessments, comprehensive emergency treatment plan and discharge planning
IndicationsFor presentations with serious symptoms where treatment should begin immediately or evaluation for EOB/inpatient admission is needed
Timing/Billing codeMust be initiated within six hours of being received into the CPEP; Rate/procedure code: 4008 (Full Emergency Visit)
inv-53: EOB (Extended Observation Bed) — definition and duration
EOB descriptionA bed in or adjacent to the CPEP emergency room for individuals requiring extensive evaluation, observation, assessment, or stabilization of acute psychiatric symptoms
Calculated start time72-hour period begins when the individual is received into the CPEP (completed registration and record created)
Operational hoursEOBs operate 24 hours per day, seven days a week and include appropriate sleeping, toilet/bath, and dietary facilities
inv-54: Voluntary Admission definition
DefinitionVoluntary admission: a person has a mental illness for which care as a patient in a CPEP is essential and the person understands and consents to such care (per MHL Sec. 9.13)
FormsFront page of OMH Form 476 to be completed for voluntary CPEP admission; provide notice of status and rights
ScopeVoluntary admission may apply to EOB as well
inv-55: CPEP emergency standard definition
DefinitionCPEP emergency standard: a person may have a mental illness for which immediate observation, care and treatment in a CPEP is appropriate and which is likely to result in serious harm to self or others
Examination requirementA staff physician, preferably a psychiatrist, must within 6 hours after receipt in the CPEP examine and determine that the individual meets the emergency standard
ConsequencesMeeting the emergency standard may lead to EOB admission, involuntary retention under MHL sections, or inpatient transfer as appropriate
inv-56: Extended Observation Bed (EOB) — involuntary admission note
Involuntary EOB admission noteTo involuntarily admit to an EOB, a staff psychiatrist must within 24 hours after receipt examine and confirm the initial finding that the individual meets the CPEP emergency standard; then the person must be moved to an EOB
Retention limitRetention in an EOB shall not exceed 72 hours (voluntary or involuntary)
Legal basisDirector may involuntarily receive and retain persons in EOB who are known or suspected to have mental illness likely to result in serious harm
inv-57: Full Emergency Visit (4008)
Code/Name4008 — Full Emergency Visit
DescriptionFace-to-face interaction with a psychiatrist and other clinical staff resulting in comprehensive psychiatric emergency treatment plan and discharge plan
Billing ruleIf both triage and full visit occur same day, reimbursement is for the full emergency visit
inv-58: Triage and Referral Visit (4007)
Code/Name4007 — Triage and Referral Visit
DescriptionFace-to-face interaction between patient and staff physician or psychiatric nurse practitioner to determine scope of emergency service; includes mental health diagnostic exam and discharge planning if discharged
TimingInitiated as soon as possible and within six hours after received into the CPEP
inv-59: Extended observation bed detailed definition
Detailed definitionAn extended observation bed is a bed in or adjacent to the CPEP emergency room designed to provide, for a period up to 72 hours, a safe environment for individuals who require extensive evaluation, assessment, or stabilization of acute psychiatric symptoms
Services includedObservation, nursing assessments each shift, daily psychiatric assessment, therapeutic programming, risk/safety planning, and discharge planning
Operational noteEOBs operate 24/7 and are used for substance metabolism, collateral gathering, and short-term recovery-oriented counseling
inv-60: Full emergency visit detailed description
Detailed descriptionFull emergency visit is a face-to-face interaction with a psychiatrist and clinical staff including psychiatric diagnostic exam, psychosocial assessment, medical exam, and development of a comprehensive psychiatric emergency treatment plan and discharge plan
When indicatedShould be used for serious presenting symptoms and when treatment should begin immediately or when evaluating for EOB or inpatient admission
Billing implicationsOne full emergency visit may be billed per calendar day; supersedes triage and referral reimbursement if both occur
inv-61: Triage and referral detailed description
Detailed descriptionTriage and referral is a face-to-face interaction with a staff physician or psychiatric nurse practitioner to determine the scope of emergency service required; includes psychiatric diagnostic exam and discharge planning when applicable
RoleDetermines need for further evaluation, full emergency visit, EOB admission, or discharge with linkage to community services
Billing implicationsOne triage and referral visit may be billed per calendar day unless superseded by a full emergency visit
inv-62: Crisis outreach definition
DefinitionCrisis outreach: face-to-face psychiatric emergency services provided outside an emergency room setting including evaluation, assessment, stabilization, therapeutic communication, coordination with supports, safety planning, referral, linkage, and peer services
SettingsMay be provided in the community or other clinical areas within the hospital; does not have to result in a CPEP visit
Role in dischargeFor individuals discharged from the CPEP, crisis outreach facilitates community tenure and linkage to community-based providers
CPEP / EOB Admission Criteria:
Staff physician determines individual may have mental illness/co-occurring disorder requiring immediate observation/care/treatment in CPEP and likely to result in serious harm to self or others; complete OMH Form 476 front page and provide notice of rights.
Staffing and documentation requirements apply.
Continued Observation: Retain for observation and treatment with reevaluation by staff psychiatrist within 24 hours; convert to EOB or discharge based on reassessment.<=24 hours before reevaluation
inv-65: CPEP Emergency / Extended Observation
CPEP emergency admission: Individual meets CPEP emergency standard (risk of serious harm to self/others); staff physician examination within six hours confirming emergency standard.6 hours
EOB involuntary admission confirmation: Staff psychiatrist must, within 24 hours of arrival, examine and confirm that the individual meets emergency standard and would benefit from extended observation and treatment before involuntary EOB admission.24 hours
EOB continued stay: Ongoing assessment confirms individual continues to meet emergency admission requirements; EOB stays permitted up to 72 hours from CPEP admission, after which discharge or inpatient admission per MHL may occur.72 hours
inv-66: Emergency/Extended Observation
Admission indications: Individuals whose presenting symptoms are serious, require immediate commencement of treatment, or are being evaluated for retention in an extended observation bed or inpatient admission.clinical determination
Full emergency visit should be provided in these cases.
Continued retention in EOB: Daily written documentation of need for continued retention is required for those receiving services up to 72 hours; no involuntary retention in CPEP beyond 24 hours unless admitted to EOB.daily
inv-67: Extended Observation / Emergency
Admission to extended observation bed: Director may involuntarily admit/retain a person in an extended observation bed if known or suspected to have mental illness likely to result in serious harm to self/others and immediate observation, care and treatment in the CPEP is appropriate.clinical judgment of risk
Retention shall not exceed 72 hours.
Continued stay in extended observation: Retention in extended observation bed is limited to 72 hours (voluntary or involuntary); extended observation billing only when held more than 24 hours; if admitted to inpatient unit during observation, inpatient billing applies.<=72 hours
Treatment plans should include medications (standing/prn), non-pharmacological interventions, family/collateral involvement, individualized risk plans, observation level and frequency of reassessments, medical care plans, activity/peer services, and linkages to social supports.
as applicable
May be documented by psychiatrist or psychiatric nurse practitioner where appropriate.
inv-71: Crisis outreach / Follow-up
Crisis outreach components: Crisis outreach may include therapeutic communication, coordination with supports, psychiatric consultation, safety planning, referral, linkage, peer services, and medication management when appropriate to support stabilization and linkage to care.as clinically indicated
Follow-up services may be reimbursed to MMCOs if provided within 14 days of a qualifying crisis episode (see billing guidance).
Transitional intentFollow-up is intended to be transitional and not a replacement for ongoing community treatment
inv-74: EOB stay maximum duration — 72 hours
Maximum EOB stay72 hours from time the individual is received into the CPEP
Start of clock72 hours begins when registration is completed and a record is created (received)
Post-72 actionsAfter 72 hours the person must be discharged or transferred to inpatient services if criteria met
inv-75: Maximum retention in CPEP before inpatient admission/transfer — 24 hours
Maximum retention before inpatient transferAn individual should not be retained in a CPEP longer than 24 hours from admission unless admitted to an EOB
ExceptionRetention beyond 24 hours is permitted only if the individual is admitted to an extended observation bed
Inpatient conversionIndividuals meeting inpatient criteria should be transferred to inpatient services as soon as possible
inv-76: CPEP visit reimbursement (4007 or 4008) — one triage and referral OR one full emergency visit
Per-day reimbursement ruleAn individual may receive one triage and referral (4007) OR one full emergency visit (4008) per calendar day; if both occur, reimbursement is for the full emergency visit
Crisis outreach comboA provider may be reimbursed for one crisis outreach service plus either one triage/referral or one full emergency visit per individual per calendar day
Multiple services claim handlingIf more than one service is provided, separate claims must be submitted (one claim per rate code)
inv-77: triage and referral (4007) or full emergency visit (4008) — one per day
One per day limitOnly one triage and referral (4007) or one full emergency visit (4008) may be billed per individual per calendar day
Full visit supersedesIf both triage and full emergency visit occur in the same day, reimbursement is for the full emergency visit
Billing noteProviders must submit separate claims when multiple services/rate codes are provided on the same day
inv-78: extended observation bed (4049) — up to 72 hours
EOB code and limitExtended observation bed (4049) — retention/claiming permitted up to 72 hours from initial arrival; EOB rate claimable only after >24 hours
Billing cadenceAdmission to EOB is, for billing, the calendar day after the calendar day the full or brief visit is completed; subsequent calendar day claims up to 72 hours
Inpatient admission impactIf admitted to inpatient unit, EOB rate is not claimed and inpatient rate applies beginning on admission