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Statement
Admission to Hospital-based, outpatient Psychiatric programs is based on a
need for evaluation, observation control and treatment of psychiatric
symptoms. The intensity of service provided is dependent upon the patient's
symptoms and ability to function in their environment. These patients,
whose severity of symptoms are such that an intense, daily program as
provided in a Partial Hospitalization Program(PHP) is not required, are
appropriate for the outpatient setting.
Outpatient clinical services are to be provided to those patients who
consent and are capable of actively participating in the services, and who
demonstrate a reasonable expectation of improvement in their disorder or
condition as a result of the active treatment provided. The condition
should not be of a chronic nature.
Services Covered
1. Individual or Group Psychotherapy with physicians, psychologists or
other mental health staff authorized by the State in which they practice.
The state licensure or authorization must specify that the providers scope
of practice includes the provision of clinical psychotherapy for the
treatment of mental illness.
2. Occupational Therapy (OT) services are covered. To be eligible, the
services must require the skills of a qualified Occupational Therapist or
an Occupational Therapy Assistant. Services must not be recreational or
diversionary.
3. Services of a licensed Clinical Social Worker, trained psychiatric
registered nurse and other staff trained to work with psychiatric patients.
4. Drugs and biologicals furnished to outpatients for therapeutic purposes,
but only if they cannot be self-administered. (CMS Pub 100-2, 6§20.4)
5. Activity therapies that are individualized and essential for the
treatment of the patient's condition. There must be clear documentation
that justifies the need for each and the services must not be recreational
or diversionary.
6. Family Counseling Services. Counseling services with members of the
household are covered only if the primary purpose of such counseling is the
treatment of the patient's condition. (See Coverage Issues Manual, § 35-14)
7. Patient Education Programs in which the educational activities are
directly related to the treatment of the patient. (See Coverage Issues
Manual, § 80-1)
8. Diagnostic services for the purpose of diagnosing those individuals for
whom it is necessary to determine functioning and interactions, to identify
problem areas and to formulate a treatment plan. It is not expected that a
patient who has been in a inpatient psychiatric program, or a partial
program would require further diagnostic services. If further psychological
testing is completed, there must be documentation in the clinical record
supporting the need for those services.
The program is to be under the direction of a physician (M.D./D.O.) trained
in the treatment of psychiatric disorders, and who is licensed by the State
in which he/she practices
Incident to Physician Services
Services must be incident to physician services. To be covered as
"incident to" physician services:
a. Outpatient clinical services are furnished during a course of treatment
initiated by the physician, and under a physician's orders. The physician
performs a psychiatric evaluation and established the treatment plan within
24 hours of admission, directs and supervises the treatment, and conducts
subsequent professional services.
b. The services provided and related supplies must be furnished as an
integral, although incidental, part of the physician's professional service
in the course of diagnosis or treatment of an illness or injury.
c. When a physician writes an order for services and refers the patient to
the outpatient psychiatric program, the physician must initiate the
management of the course of treatment.
d. Diagnostic services are covered when provided by the hospital whether
furnished in the hospital or at other locations. Outpatient therapeutic
services, furnished incident to physician's services, are covered when
furnished outside the hospital only if there is direct personal supervision
by a physician. Thus, it may be necessary to distinguish between diagnostic
and therapeutic services when services are provided outside the hospital.
e. The physician must routinely provide and document clinical supervision
and direction to any therapist involved in the patient's treatment via the
Master Treatment Plan.
f. There must be documentation that the attending physician participated in
the management of the course of treatment of the patient.
Reasonable Expectation of Improvement
Services must be reasonable and necessary for the diagnosis and treatment
of the patient's condition. This means the service provided must reasonably
be expected to improve the patient's condition.
The treatment must, at a minimum, be designed to reduce or control the
patient's psychiatric symptoms so as to prevent relapse which would require
a higher level of care, and improve the patient's level of functioning.
It is not necessary that a course of therapy have as its goal, the
restoration of the patient to the level of functioning exhibited prior to
the onset of the illness, although this may be appropriate for some
patients. For patients with long-term, chronic conditions, control of
symptoms and maintenance of a functional level, to avoid further
deterioration is an acceptable expectation of improvement.
"Improvement" in this context is measured by comparing the effect
of continuing treatment versus discontinuing it. (CMS Pub 100-2, 6§70)
Meeting this criterion of improvement in patients with long-term, chronic
conditions is measured by gradually reducing the treatment and measuring the
effect on the patient. When stability can be maintained without further
treatment or with less intensive treatment, it is determined that the
"improvement" criterion has been met and the patient should be
discharged from the Outpatient Psychiatric Services and transitioned to a
less intensive treatment modality which may include Psychotherapy/Med
Management on an intermittent basis.
Intensity of Services
In order for treatment to be medically necessary, treatment services must
be delivered at the lowest level of intensity that still establishes and
maintains improvement as defined above. Attempts at reducing the level of
services must be made at appropriate intervals and documented to establish
medical necessity for services.
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