|
Inpatient psychiatric hospitalization provides twenty four (24)
hours of daily care in a structured, intensive, and secure setting for
patients who cannot be safely and/or adequately managed at a lower level of
care. This setting provides daily physician (MD/DO) supervision,
twenty-four (24) hour nursing/treatment team evaluation and observation,
diagnostic services, and psychotherapeutic and medical interventions.
Inpatient psychiatric care may be delivered in a Psychiatric Hospital, a
Psychiatric Hospital Acute Care Unit within a Psychiatric Institution, or a
Psychiatric Inpatient Unit within a General Hospital as defined in CMS Pub
100-1, 5-§20.3, 100-1, 5-§20.5 and 100-1, 5-§20.7. This LCD addresses
psychiatric care in a DRG-excluded unit; the review of DRG based claims
from non-excluded psychiatric units of acute care hospitals is the
responsibility of the QIO and is not within the purview of the Fiscal
Intermediary.
Medicare patients admitted to inpatient psychiatric hospitalization must be
under the care of a physician who is knowledgeable about the patient. The
physician must certify/recertify (see “Documentation Requirements” section)
the need for inpatient psychiatric hospitalization. The patient must
require “active treatment” of his/her psychiatric disorder. The patient or
legal guardian must provide written informed consent for inpatient
psychiatric hospitalization.
Admission Criteria (Physician Decision to
Admit):
An admission is not considered medically necessary until medical necessity
is established by the admitting physician. Since a delay in performing the
medical (psychiatric) history and physical examination beyond the initial
24 hours is typically a matter of physician convenience, if the admitting
physician at the time of the initial H&P does not establish a need for
an inpatient stay, the entire stay will usually be considered appropriate
for outpatient observation and an inpatient claim will be denied as not
medically necessary. The initial evaluation should therefore be performed
within the first 24 hours of the stay if there is any doubt in the mind of
the attending physician as to the necessity for the inpatient level of
care.
Admission Criteria (Intensity of Service):
The patient must require intensive, comprehensive, multimodal treatment
including 24 hours per day of medical supervision and coordination because
of a mental disorder. The need for 24 hours of supervision may be due to
the need for patient safety, psychiatric diagnostic evaluation, potential
severe side effects of psychotropic medication associated with medical or
psychiatric co-morbidities, or evaluation of behaviors consistent with an
acute psychiatric disorder for which a medical cause has not been ruled
out.
The acute psychiatric condition being evaluated or treated by inpatient
psychiatric hospitalization must require active treatment, including a
combination of services such as intensive nursing and medical intervention,
psychotherapy, occupational and activity therapy. Patients must require
inpatient psychiatric hospitalization services at levels of intensity and
frequency exceeding what may be rendered in an outpatient setting, including
psychiatric partial hospitalization. There must be evidence of failure at,
or inability to benefit from, a less intensive, outpatient program, or
other evidence that a less comprehensive program would be unsafe or
medically unsound. Claims for care delivered at an inappropriate level of
intensity will be denied.
Admission Criteria (Severity of Illness):
A medically appropriate inpatient admission should typically meet one or
more of the following criteria:
1. Threat to self requiring 24-hour professional observation
a.) suicidal ideation or gesture within 48 hours prior to admission (plan,
means and intent)
b.) self mutilation (actual or threatened) within 48 hours prior to
admission
c.) chronic and continuing self destructive behavior (e.g., bulemic
behaviors, substance abuse) that poses a significant and/or immediate
threat to life, limb, or bodily function.
2. Threat to others requiring 24-hour professional observation:
a.) assaultive behavior threatening others within 48 hours prior to
admission.
b.) significant verbal threat to the safety of others within 48 hours prior
to admission.
3. Command hallucinations directing harm to self or others where there is
the risk of the patient taking action on them.
4. Acute disorder/bizarre behavior or psychomotor agitation or retardation
that interferes with the activities of daily living (ADLs) so that the
patient cannot function at a less intensive level of care during evaluation
and treatment.
5. Cognitive impairment (disorientation or memory loss) due to an acute
Axis I disorder that endangers the welfare of the patient or others.
6. A mental disorder causing major disability in social, interpersonal,
occupational, and/or educational functioning that is leading to dangerous
or life-threatening functioning, and that can only be addressed in an acute
inpatient setting.
7. A mental disorder that causes an inability to maintain adequate
nutrition or self-care, and family/community/social support cannot provide
reliable, essential care, so that the patient cannot function at a less
intensive level of care during evaluation and treatment.
8. Failure of outpatient psychiatric treatment so that the beneficiary
requires 24-hour professional observation and care. Reasons for the failure
of outpatient treatment could include:
a.) Increasing severity of psychiatric symptoms;
b.) Noncompliance with medication regimen due to the severity of
psychiatric symptoms;
c.) Inadequate clinical response to psychotropic medications;
d.) Due to the severity of psychiatric symptoms, the patient is unable to
participate in an outpatient psychiatric treatment program.
An inpatient admission may be medically appropriate in circumstance not
listed above; however those occasions are uncommon and should be examined
carefully to ensure that less intensive settings are not reasonable. For
all symptom sets or diagnoses, the severity and acuity of symptoms and the
likelihood of response to treatment, combined with the requirement for an
intensive, 24-hour level of care, are the significant factors in
determining the necessity of inpatient psychiatric treatment.
Active Treatment:
The italicized text in this portion of the LCD is quoted verbatim
from CMS Pub 100-2, 2-§20:
For services in a hospital to be designated as "active
treatment," they must be:
(a) provided under an individualized treatment or diagnostic plan,
(b) reasonably expected to improve the patient's condition or for the
purpose of diagnosis, and
(c) supervised and evaluated by a physician.
Such factors as diagnosis, length of hospitalization, and the degree of
functional limitation, while useful as general indicators of the kind of
care most likely being furnished in a given situation, are not controlling
in deciding whether the care was active treatment. The following is a
discussion of each element of the above definition of active treatment:
l. Individualized Treatment or Diagnostic Plan.-- The services must
be provided in accordance with an individualized program of treatment or
diagnosis developed by a physician in conjunction with staff members of
appropriate other disciplines on the basis of a thorough evaluation of the
patient's restorative needs and potentialities. Thus, an isolated service,
e.g., a single session with a psychiatrist, or a routine laboratory test
not furnished under a planned program of therapy or diagnosis would not
constitute active treatment, even though the service was therapeutic or
diagnostic in nature. The plan of treatment must be recorded in the
patient's medical record in accordance with section 405.1037(a)(8) of the
regulations on Conditions of Participation for Hospitals.
2. Services Expected to Improve the Condition or for Purpose of
Diagnosis.--The services must be reasonably expected to improve the
patient's condition or must be for the purpose of diagnostic study. It is
not necessary that a course of therapy have as its goal the restoration of
the patient to a level which would permit discharge from the institution
although the treatment must, at a minimum, be designed both to reduce or
control the patient's psychotic or neurotic symptoms which necessitated
hospitalization and improve the patient's level of functioning.
The kinds of services which meet the above requirements would include not
only psychotherapy, drug therapy, and shock therapy, but also such
adjunctive therapies as occupational therapy, recreational therapy, and
milieu therapy, provided the adjunctive therapeutic services are expected
to result in improvement (as defined above) in the patient's condition. If,
however, the only activities prescribed for the patient are primarily
diversional in nature, i.e., to provide some social or recreational outlet
for the patient, it would [not] be regarded as treatment to improve the
patient's condition. In many large hospitals these adjunctive services are
present and part of the life experience of every patient. In a case where
milieu therapy (or one of the other adjunctive therapies) is involved, it
is particularly important that this therapy be a planned program for the
particular patient and not one where life in the hospital is designated as
milieu therapy.
In accordance with the above definition of "improvement," the
administration of antidepressant or tranquilizing drugs which are expected
to significantly alleviate a patient's psychotic or neurotic symptoms would
be termed active treatment (assuming that the other elements of the
definition are met). However, the administration of a drug or drugs does
not of itself necessarily constitute active treatment. Thus, the use of
mild tranquilizers or sedatives solely for the purpose of relieving anxiety
or insomnia would not constitute active treatment.
3. Services Supervised and Evaluated by a Physician.-- Physician
participation in the services is an essential ingredient of active
treatment. The services of qualified individuals other than physicians,
e.g., social workers, occupational therapists, group therapists,
attendants, etc., must be prescribed and directed by a physician to meet
the specific needs of the individual. In short, the physician must serve as
a source of information and guidance for all members of the therapeutic
team who work directly with the patient in various roles. It is the
responsibility of the physician to periodically evaluate the therapeutic
program and determine the extent to which treatment goals are being
realized and whether changes in direction or emphasis are needed. Such
evaluation should be made on the basis of periodic consultations and
conferences with therapists, reviews of the patient's medical record, and
regularly scheduled patient interviews--at least once a week. (Although it is CMS’ requirement that the
physician see the patient at least once per week, this is a dated
reference, referring to a time when patients were hospitalized for long
periods of time. The current standard of practice is that the physician
usually sees the patient at least five times per week, and Riverbend
defines that as a local requirement.)
Although in an institutional setting the services of a physician may be
readily available, the general pattern is for the physician to visit the
patient only periodically, delegating to nursing personnel the
responsibility for intensive observation of patients, where it is
necessary. Such periodic visits to a patient do not in themselves
constitute active treatment. Conversely, when the physician periodically
evaluates the therapeutic program to determine the extent to which
treatment goals are being realized and whether changes in direction or
emphasis are needed based on consultations and conferences with therapists,
review of the patient's progress as recorded on his medical record and his
periodic conversations with the patient, active treatment would be
indicated. The treatment furnished the patient should be documented in the
medical record in such a manner and with such frequency as to provide a
full picture of the therapy administered as well as an assessment of the
patient's reaction to it. (See section 405.1037(a)(9) and (10) of the
regulations on Conditions of Participation for Hospitals.)
A finding that a patient is not receiving active treatment will not in
itself preclude payment for physicians' services under Part B. As long as
the professional services rendered by the physician are reasonable and
necessary for the care of the patient, such services would be reimbursable
under the medical insurance program.
B. Principles for Evaluating a Period of Active Treatment.--As indicated,
the period of time covered by the physician's certification is referred to
as a "period of active treatment." This period should include all
days on which inpatient psychiatric hospital services were provided because
of the individual's need for active treatment--not just the days on which
specific therapeutic or diagnostic services were rendered. For example, a
patient's program of treatment may necessitate the discontinuance of
therapy for a period of time or it may include a period of observation,
either in preparation for or as a followup to therapy, while only maintenance
or protective services are furnished. If such periods were essential to the
overall treatment plan, they would be regarded as part of the period of
active treatment.
The fact that a patient is under the supervision of a physician does not
necessarily mean that he is getting active treatment. For example, medical
supervision of a patient may be necessary to assure the early detection of
significant changes in his condition; however, in the absence of a specific
program of therapy designed to effect improvement, a finding that the
patient is receiving active treatment would be precluded.
The program's definition of active treatment does not automatically exclude
from coverage services rendered to patients who have conditions which
ordinarily result in progressive physical and/or mental deterioration.
Although patients with such diagnoses will most commonly be receiving
custodial care, they may also receive services which meet the program's
definition of active treatment. This might be the case, for example, where
a patient with Alzheimer's or Pick's disease received services designed to
alleviate the effects of paralysis, epileptic seizures, or some other
neurological symptom, or where a patient in the terminal stages of any
disease received life- supportive care. A period of hospitalization during
which services of this kind were furnished would be regarded as a period of
active treatment. (CMS Pub
100-2, 2-§20) Note, however, that to qualify for inpatient psychiatric
care, it is the need for inpatient psychiatric services that determines the
medical appropriateness of the stay in an excluded psychiatric unit. A
medical condition, be it an indolent refractory condition such as
Alzheimer’s or the terminal stages of a fulminant disease, is not medically
appropriate for an inpatient psychiatric stay when the psychiatric
condition is a small part of the need for services. These patients may be
appropriate for acute or long term inpatient or SNF care with psychiatric
support in any of those environments. Conversely, a patient with
psychiatric disease may have medical comorbidities that would render the
psychiatric care ineffective in a less intensive setting; such a patient is
medically appropriate for an inpatient psychiatric stay. It is also true
that, whereas the patient must have a psychiatric diagnosis that is
amenable to treatment, it is not necessary that the medical prognosis must
be favorable as well.
Discharge Criteria (Intensity of Service):
Patients in inpatient psychiatric care may be discharged by stepping down
to a less intensive level of outpatient care. Stepping down to a less
intensive level of service than inpatient hospitalization would be
considered when patients no longer require 24-hour observation for safety,
diagnostic evaluation, or treatment as described above. These patients
would become outpatients, either receiving psychiatric partial
hospitalization or individual outpatient mental health services, rendered
and billed by appropriate providers.
Discharge Criteria (Severity of Illness):
Patients whose clinical condition improves or stabilizes and who do not
still require 24-hour observation available in an inpatient psychiatric
unit should be stepped down to outpatient care. Patients whose Global
Assessment of Functioning is above 30 would usually be appropriate for
discharge to a less intense level of care. Patients unwilling or unable to
participate in active treatment of their psychiatric condition would also
be appropriate for discharge.
Qualified Providers:
Inpatient psychiatric diagnostic and treatment services rendered to
Medicare beneficiaries must be provided by individuals licensed or
otherwise authorized by the state in which they practice, to render such
services. Non-physician practitioners, licensed or authorized by the state,
may perform duties within their scope of practice, such as individual
and/or group psychotherapy, family counseling, occupational therapy, and
diagnostic services. Providers of inpatient psychiatric services may
include:
Physicians:
1. Medical Doctor (MD) (See Title XVIII of the Social Security Act, Section
1861[r].)
2. Doctor of Osteopathy (DO) (See Title XVIII of the Social Security Act,
Section 1861[r].)
Nonphysician Clinical Practitioners:
1. Clinical Psychologists (See Title XVIII of the Social Security Act,
Sections 1861[s][2][M] and 1861[hh][2][ii].)
2. Clinical Nurse Specialists (CNSs), or other registered nurses with
appropriate mental health training and/or experience (See Title XVIII of
the Social Security Act, Sections 1861[s][2][K][ii] and 1861[aa][5][B].)
3. Licensed/certified clinical social workers (CSWs), masters-prepared
social workers with additional clinical training AND licensure or state
certification (See Title XVIII of the Social Security Act, Sections 1861[s][2][N]
and 1861[hh][1].)
4. Occupational Therapists (See Title XVIII of the Social Security Act,
Section 1861[g] and 42 CFR Sections 440.110 and 484.4.)
Other Providers Licensed or Otherwise Authorized by the State:
1. Marriage and Family Therapists (MFTs), as allowed by state law.
2. Registered Therapists and Certified Alcohol and Drug Counselors, as
allowed by state law.
3. Recreational Therapists, as allowed by state law.
4. Registered pharmacists who may provide individual medication counseling
and periodic educational groups
5. Other licensed or certified mental health practitioners whose scope of
practice requires a specific level of supervision (e.g., Psychological
Assistants, MFT interns and non-licensed/certified Masters in Social Work
may provide services within the limits of state scope of practice,
licensure, and regulations).
Other Comments:
1. Psychological Interns with less than a Master's Degree are not
considered a provider of service.
2. An appropriately licensed supervisor must observe and provide
one-on-one, in-person, supervision for at least one hour per week for
non-licensed/certified MSWs, MFT interns, and psychological assistants. If
state-mandated supervision exceeds this level, the highest level of
supervision is required. Such supervision need not occur on the inpatient
psychiatric unit but must be documented and documentation must be
maintained in the hospital and available for inspection upon request by
Medicare or submitted to Medicare when requested.
NOTE: Limits of local, state or federal scope of practice acts,
legislation, and licensure regulations apply to all practitioners within an
inpatient psychiatric treatment unit. In all cases, the most restrictive
limit shall apply (e.g., who may or may not perform individual or group
psychotherapy).
A claim that does not fulfill the coverage requirements described above may
be given individual consideration based on review of all pertinent medical
information.
Reasons for Denial:
1. Failure to provide documentation to support the necessity of test(s) or
treatment(s) may result in denial of claims or services under Sections
1862(a)(1)(A) and 1833(e) of the Title XVIII of the Social Security Act.
This includes medical records:
a. that do not support the reasonableness and necessity of service(s)
furnished;
b. in which the documentation is illegible; or
c. where medical necessity for inpatient psychiatric services is not
appropriately certified.
2. The following services do not represent reasonable and medically
necessary inpatient psychiatric services and coverage is excluded under
Title XVIII of the Social Security Act, Section 1862(a)(1)(A):
a. Services which are primarily social, recreational or diversion
activities, or custodial or respite care;
b. Services attempting to maintain psychiatric wellness for the chronically
mentally ill;
c. Treatment of chronic conditions without acute exacerbation;
d. Vocational training;
e. Medical records that fail to document the required level of physician
supervision and treatment planning process;
f. Electrosleep therapy (CIM 35-18);
g. Electrical Aversion Therapy for treatment of alcoholism (CIM 35-23.1);
h. Hemodialysis for the treatment of schizophrenia (CIM 35-51);
i. Transcendental Meditation (CIM 35-92);
j. Multiple Electroconvulsive Therapy (MECT) (CIM 35-103).
3. It is not reasonable and medically necessary to provide inpatient
psychiatric hospital services to the following types of patients, and
coverage is excluded under Title XVIII of the Social Security Act, Section
1862(a)(1)(A):
a. Patients who require primarily social, custodial, recreational, or
respite care;
b. Patients whose clinical acuity requires less than twenty-four (24) hours
of supervised care per day;
c. Patients who have met the criteria for discharge from inpatient
hospitalization;
d. Patients whose symptoms are the result of a medical condition that
requires a medical/surgical setting for appropriate treatment;
e. Patients whose primary problem is a physical health problem without a
concurrent major psychiatric episode;
f. Patients with alcohol or substance abuse problems who do not have a
combined need for "active treatment" and psychiatric care that
can only be provided in the inpatient hospital setting. (CIM 35-22 &
35-22.2);
g. Patients for whom admission to a psychiatric hospital is being used as
an alternative to incarceration.
4. Listing an ICD-9-CM code in the Mental Disorders category (290 -
319) does not assure coverage of the specific service. Coverage criteria
specified in this LCD shall be applied to determine appropriate
reimbursement.
5. Medicare contractors may automatically deny a claim without any manual
review if a national coverage decision or an LCD specifies the
circumstances under which a service is denied and those circumstances
exist, or the service is specifically excluded from Medicare coverage by
statute.
6. When an admission is denied, all services for that date of service
related to that admission will also be denied.
Other Comments
This does NOT address the following issues:
1. Life Time Limits and Spell of Illness Limits to psychiatric
hospitalization services as defined by the CMS Pub 100-1, 4-§10,100-1,
4-§10,100-1, 4-§10.2, 100-1, 4-§20,100-1, 4-§30, 100-1, 4-§40, and 100-1,
4-§50 and CMS Publication 13, Medicare Intermediary Manual, Sections
100-2, 4-§10-§50. Nothing in this article can be used to either expand or
contract those limits; however, coverage may be denied for medical
necessity reasons even though the beneficiary has not exhausted the life
time limit or spell of illness limit for psychiatric hospitalization
services.
2. Notice to Beneficiaries as described in CMS Publication 10, Medicare
Hospital Manual, Sections 100-4, 2-§80-§80.3. All requirements related
to discharge and coverage notification as described in the Medicare
interpretive manuals apply.
3. Psychiatric Advance Directives as defined in 42 CFR Section
482.13(b)(3). All requirements related to Psychiatric Advance Directives
must be met as part of the Hospital Conditions of Participation for
Patients Rights.
4. Chemical or Physical Restraints, Seclusion, or Behavior Management
within a psychiatric plan of care. These issues are addressed extensively
in the Hospital Patient's Rights Legislation published in 64 FR 36070, July
2, 1999. All applicable requirements described in this publication must be
met.
5. Certification of Facilities as psychiatric hospitals, psychiatric
Inpatient Units within a Psychiatric Institution, or Psychiatric Inpatient
Units within a General Hospital as defined in CMS Pub 100-1, 5-§20.3, §20.5
and §20.7. All requirements described in the Medicare interpretive manuals
apply.
6. Items and Services Furnished, Paid for or Authorized by Governmental
Entities as defined by CMS Pub 100-2, 16-§50: Payment may be made
for items and services furnished by a participating State or local
government hospital, including a psychiatric hospital, which serves the
general community. A psychiatric hospital to which patients convicted of
crimes are committed involuntarily is considered to be serving the general
community if State law provides for voluntary commitment to the
institution. However, payment may not be made for services furnished in
State or local hospitals which serve only a special category of the
population, but do not serve the general community, e.g., prison hospitals.
Notice to beneficiaries requirements apply. See number 2 in the “Other
Comments” section above.
|