Psychiatric Inpatient Hospitalization (L30441)

General Documentation Information
HCPCS codes not listed as €œICD-9 Codes That Support Medical Necessity €� may be covered upon request to the Contractor Medical Director for individual consideration with supporting evidence of medical necessity in the specific case and must meet the specified criteria of this determination (Title XVIII of the Social Security Act, Section 1862[a][1][A].) The codes selected are generally those codes that appear in the ICD-9-CM and that are defined in the Diagnostic and Statistical Manual, fourth edition (DSM-IV-TR „¢).

Documentation that supports medical necessity and active treatment may take many forms. These documentation requirements are intended to help providers identify those documentation elements that will best support the medical necessity of the services they render. It is not expected that every item of these documentation requirements will appear in every record. Upon medical review, the IPF record will be reviewed as a whole, and services may be denied only if there is insufficient documentation to support the medical necessity of the claim, despite the presence of some missing or illegible documentation.

Medical record documentation must meet the criteria contained in this policy. Medical records must be made available, as hard copies, upon request of the Medicare contractor. The documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests and/or procedures. The diagnoses listed on the claim must be supported in the medical record documentation.

Required documentation for claim submission:
1. Physician certification for admission
2. Diagnosis according to the DSM IV and any comorbidity diagnoses
3. Progress notes from all providers of services
4. Recertification documentation
5. Initial psychiatric evaluation (see detailed requirements under Initial Psychiatric Evaluation)
6. Physician orders
7. Plan of treatment including discharge planning

Certification/ Recertification - General Requirements
Payments may be made for covered hospital services only if a physician certifies and recertifies to the medical necessity for the services at designated intervals of the inpatient stay. Appropriate supporting material may be required. The physician certification or recertification statement must be based on a current evaluation of the patient's condition and authorized by the attending physician, or by a member of the hospital's medical staff who has knowledge of the case. Ordinarily for purposes of certification and recertification, a €œphysician €� must meet the CMS physician definition (Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.2 and Chapter 5, Section 70 and 70.3 and Chapter 4, Section 10.2). (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10).

At the time of admission or as soon thereafter as is reasonable and practicable, a physician (the admitting physician or a medical staff member with knowledge of the case) must certify the medical necessity for inpatient psychiatric hospital services. The first recertification is required as of the 12th day of hospitalization. Subsequent recertifications will be required at intervals established by the hospitals utilization review committee (on a case-by-case), but no less frequently than every 30 days (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.9).

For patients admitted to a general hospital, regardless of whether the patients are under PPS, a physician certification is not required at the time of admission for patient services. For services continued over a period of time or for a day outlier case... a physician must certify or recertify the continued need for the services at specified intervals (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10). (See also CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.9.)

The individual hospital determines the method by which certifications and recertifications are to be obtained and the format of the statement. Thus, the medical and administrative staffs of each hospital may adopt the procedure they find most convenient and appropriate (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.5).

There is no requirement that the certification or recertification be entered on any specific form or handled in any specific way, as long as the approach adopted by the hospital permits the intermediary to determine that the certification and recertification requirements are, in fact, met. The certification or recertification could, therefore, be entered or preprinted on a form the physician already has to sign; or a separate form could be used. If all the required information is included in progress notes, the physician's statement could indicate that the individual's medical record contains the information required and that continued hospitalization is medically necessary (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement
Manual, Chapter 4, Section 10.5).

If an individual is admitted to a hospital (including a psychiatric hospital) before he/she is entitled to hospital insurance benefits (for example, before attainment of age 65), no certification is required as of the date of admission or entitlement. Certifications and recertifications are required as of the time they would be required if the patient had been admitted to the hospital on the day he/she became entitled. (The time limits for certification and recertification are computed from the date of entitlement instead of the date of admission.) (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 20.2).

Certification/Recertification specific to Inpatient Psychiatric Hospitalization
The requirements for physician certification and recertification for inpatient psychiatric hospital services are similar to the requirements for certification and recertification for inpatient hospital services. However, there is an additional certification requirement: At the time of admission or as soon thereafter as is reasonable and practicable, a physician (the admitting physician or a medical staff member with a knowledge of the case) must certify the medical necessity for inpatient psychiatric hospital services. As a result, the first and second recertification for psychiatric hospital services correspond to the initial certification and first recertification requirements for inpatient hospital services (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.9).

In accordance with 42 CFR 424.14, all IPFs (distinct part units of acute care hospitals, CAHs, and psychiatric hospitals) are required to meet the following certification and recertification requirements:

The required physician's statement should certify that the inpatient psychiatric facility admission was medically necessary for either: (1) treatment which could reasonably be expected to improve the patient's condition, or (2) diagnostic study.

The physician's recertification should state:
1. That inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:
a. Treatment which could reasonably be expected to improve the patient's condition;
b. Diagnostic study;
2. The hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services, and
3. Effective July 1, 2006, physicians will also be required to include a statement recertifying that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel (CMS Publication, Medicare General Information, Eligibility, and Entitlement, 100-01, Chapter 4, Section 10.9).

For convenience, the period covered by the physician's certification and recertification is referred to a period during which the patient was receiving active treatment. If the patient remains in the hospital but the period of "active treatment" ends (e.g., because the treatment cannot reasonably be expected to improve the patient's condition, or because intensive treatment services are not being furnished), program payment can no longer be made even though the patient has not yet exhausted his/her benefits. Where the period of "active treatment" ends, the physician is to indicate the ending date in making his recertification. If "active treatment" thereafter resumes, the physician should indicate, in making his recertification, the date on which it resumed (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.9).

If a hospital fails to obtain the required certification and recertification statements in an individual case, program payments will not be made (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.1).

If the hospital s failure to obtain a certification or recertification is not due to a question as to the necessity for the services, but rather to the physician's refusal to certify based on other grounds (e.g., he/she objects in principle to the concept of certification and recertification), the hospital may not bill the program or the beneficiary for covered items or services. The provider agreement precludes the hospital from charging the patient for covered items and services (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.1).

Initial psychiatric evaluation
The initial psychiatric evaluation with medical history and physical examination should be performed within 24 hours of admission, but in no case later than 60 hours of admission in order to establish medical necessity for psychiatric inpatient hospitalization services.

In order to support the medical necessity of admission, documentation in the initial psychiatric evaluation must:
(1) Be completed within 60 hours of admission;
(2) Include a medical history;
Past medical history
Current medical history including medications
(3) Contain a record of mental status;
Current medications
Evidence of failure at or inability to benefit from outpatient treatment (lower level of care)
Past psychiatric history
History of substance abuse
Family, vocation, social history
(4) Note the onset of illness and the circumstances leading to admission;
Description of illness or exacerbation of chronic illness
(5) Describe attitudes and behavior;
Mental Status Examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self-harm and harm to others, insight, judgment, capacity for activities or activities of daily living (ADL s)
(6) Estimate intellectual functioning, memory functioning, and orientation; and
Global Assessment of Functioning Score
(7) Include an inventory of the patient s assets in descriptive, not interpretative fashion.
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2)

Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized.
1. The identification data must include the patient s legal status.
2. A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnoses of comorbid diseases as well as the psychiatric diagnoses.
3. The reasons for admission must be clearly documented as stated by the patient and/or others significantly involved.
4. The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.
5. When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.1)

A physical examination and other necessary diagnostic evaluations should be completed to the extent possible and as indicated by the patient s clinical presentation to rule out medical/neurological causes of psychiatric symptomatology. Several conditions should be treated in a medical setting as opposed to a psychiatric setting. Examples include: potentially life-threatening drug overdose, anticholinergic delirium, and neuroleptic malignant syndrome, among many others.

A team approach may be used in developing the initial psychiatric evaluation and the plan of treatment (see €œPlan of Treatment €� section below), but the physician (MD/DO) must personally document the mental status examination, physical examination, diagnosis, and certification. It will not always be possible to obtain all the suggested information at the time of evaluation. In such cases, the limited information that is obtained and documented must still be sufficient to support the need for an inpatient level of care.

Physician Orders:
Physician orders should include, but are not limited to, the following items:
1. The types of psychiatric and medical therapy services and medications;
2. Laboratory and other diagnostic testing;
3. Allergies;
4. Provisional diagnosis(es); and
5. Types and duration of precautions (e.g., constant observation X 24 hours due to suicidal plans, restraints).

Plan of Treatment:
The Plan of Treatment is the tool used by the physician and multi-disciplinary treatment team to implement the physician-ordered services and move the patient toward the expected outcomes and goals. The Plan of Treatment is a requirement. Documentation of the parameters below is suggested to support the medical necessity for the inpatient services throughout the patient s stay.

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. The plan of treatment must be recorded in the patient's medical record in accordance with 42 CFR 482.61, Conditions of Participation for Hospitals (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.3) and 42 CFR 412.27, Excluded psychiatric units: Additional requirements.

1. This individualized, comprehensive, outcome-oriented plan of treatment should be developed:
a) within the first three (3) program days after admission;
b) by the physician, the multidisciplinary treatment team, and the patient; and should be
c) based upon the problems identified in the physician s diagnostic evaluation, psychosocial and nursing assessments.

2. The plan of treatment should include:
a) the specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished;
b) the expected outcome for each problem addressed; and
c) contain outcomes that are measurable, functional, time-framed, and directly related to the cause of the patient s admission.

3. Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.

4. The initial treatment plan and updated plans must be signed by the physician and those mental health professionals contributing to the treatment plan.

Progress Notes

General:
A separate progress note should be written for each significant diagnostic and therapeutic service rendered and should be written by the team member rendering the service. Although each progress note may not contain every element, progress notes should include a description of the nature of the treatment service, the patient s status (behavior, verbalizations, mental status) during the course of the service, the patient s response to the therapeutic intervention and its relation to the long or short term goals in the treatment plan and include the credentials of the rendering provider. It should be clear from the progress notes how the particular service relates to the overall plan of care.

Physician Progress Notes:
Physician progress notes should be recorded at each patient encounter and contain pertinent patient history, changes in signs and symptoms, with special attention to changes to the patient s mental status, and results of any diagnostic testing. The notes should also include an appraisal of the patient s status and progress, and the immediate plans for continued treatment or discharge. The course of the patient s inpatient diagnostic evaluation and treatment should be able to be inferred from reading the physician progress notes.

Individual and Group Psychotherapy and Patient Education and Training Progress Notes:
Psychotherapy notes will not be requested for submission. 45 CFR Part 164.508 (a)(2) defines psychotherapy notes as notes recorded by a mental health professional that document or analyze the contents of a counseling session and that are separated from the rest of a medical record. Psychotherapy notes expressly exclude documentation of medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date. Physically integrating this information into protected psychotherapy notes does not automatically transform it into protected information.

Also note that physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes. The provider is responsible for extracting the information needed to support that the claim is reasonable and necessary.

Individual and group psychotherapy and patient education and training progress notes should describe the service being rendered, (i.e., name of group, group type, brief description of the content of the individual session or group), the patient s communications, and response or lack of response to the intervention. Each progress note should reflect the particular characteristics of the therapeutic/educational encounter to distinguish it from other similar interventions.

Discharge Plan:
It is expected as a matter of good quality of care that careful discharge planning occur to enable a successful transition to outpatient care.

Wisconsin Physicians Service (WPS) does not guarantee the continued availability of web links provided in sources.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
Significance of Source: This specialty organization publication provides definitions and background information regarding psychiatric diagnoses.

Anderson AJ, Micheels P, et al. Criteria based voluntary and involuntary psychiatric admissions modeling. International Journal of Psychosocial Rehabilitation 1998; 2(2):176-188. Retrieved May 22, 2003 from the World Wide Web: http://www.psychosocial.com/research/vol.html.
Significance of Source: This article provides background information regarding psychiatric admission criteria.

Gartner, L, Mee-Lee, D. The role and current status of patient placement criteria in the treatment of substance abuse disorders. U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2002. DHHS Publication No. (SMA) 02-3684.
Significance of Source: This Treatment Improvement Protocol (TIP) provides information useful in ascertaining the appropriate level of care for patients with addictive disorders.

Goldman RL, Weir CR, et al. Validity of utilization management criteria for psychiatry. Am J Psychiatry 1997; 154:349-354. Retrieved May 22, 2003 from the World Wide Web:
http://ajp.psychiatryonline.org/cgi/content/abstract/154/3/349.
Significance of Source: This article studies the validity of psychiatric admission criteria.

Hart A, Hopkins C, eds. ICD-9-CM 2003, 9th Revision, Clinical Modification, Sixth Edition. Salt Lake City, UT: 2002.
Significance of Source: This text provides codes and definitions for psychiatric diagnoses and is designated by CMS as the coding system physicians and those providers that are required to submit codes must use for Medicare claims submission.

Hermann RC, Leff HS, et al. Selecting process measure for quality improvement in mental healthcare. The Evaluation Center @HSRI July 2002. Retrieved July 2, 2003 from the World Wide Web: http://www.cqaimh.org/toolkit.website.pdf
Significance of Source: This publication is a tool kit designed to help healthcare organizations to identify and select measures for use in quality assessment and improvement activities related to mental healthcare.

McGovern J. Management of risk in psychiatric rehabilitation. The Psychologist 1996: pages 405-408. Retrieved May 22, 2003 from the World Wide Web:
http://www.academicarmageddon.co.uk/library/MCG.htm.
Significance of Source: This article provides a review of the assessment of the risk of self harm and harm to others.

Merck Manual of Diagnosis and Therapy, Section 15. Retrieved May 22, 2003 from the World Wide Web: http://www.merck.com/pubs/mmanual/section15/chapter194/194a.htm.
Significance of Source: This section of the compendium presents information related to psychiatric disorders requiring emergency evaluation and treatment.

Silka VR, Hauser MJ. Psychiatric assessment of the person with mental retardation. Psychiatric Annals March 1997; 27:3. Retrieved May 22, 2003 from the World Wide Web:
http://www.psychiatry.com/mr/assessment.html.
Significance of Source: This article reviews the psychiatric assessment of individuals with mental retardation.

Silver MS, Burak OR. Transfer of facility clients to inpatient psychiatry: eight criteria to consider. Journal of Healthcare Quality September/October 2002. Retrieved May 22, 2003 from the World Wide Web: http://www.allenpress.com/jhq/119/119.html.
Significance of Source: This article reviews criteria for the transfer of patients with mental retardation to inpatient psychiatric facilities.

Soderberg, P, Tungstrom, S, and Armelius, B. (2005). Reliability of global assessment of functioning ratings made by clinical staff. Psychiatric Services, April 2005 (56) 4, p 434-438. Retrieved May 22, 2009 from the World Wide Web: http://ps.psychiatryonline.org.
Significance of Source: This article reviews the reliability of the GAF in measuring putcomes.

ValueOptions, Inc. Provider Handbook, Section III, Clinical criteria and clinical practice guidelines: adult mental health facilities and programs, Subsection 2.201 (Acute inpatient mental health [adult]). Retrieved May 22, 2003 from the World Wide Web: http://www.valueoptions.com/provider/handbook/three/302b.htm.
Significance of Source: This section of the handbook outlines criteria required by this managed care organization for adult acute inpatient psychiatric admission.

Washington Peer Review Organization, General criteria set for non-physician review, Chapter 4 (Guidelines for rehabilitation, psych and addiction), revised 7/1/98 (acute psychiatric illness); revised 7/1/97 (addiction).
Significance of Source: This document provides the criteria used by this Quality Improvement Organization (QIO [formerly PRO]) for psychiatric hospitalization.

Texas Medical Foundation, QIO Criteria: Indications for Hospitalization.
Significance of Source: This document details the criteria for inpatient psychiatric admission that are required by this Quality Improvement Organization (QIO).

Other Medicare contractor (carrier and fiscal intermediaries Local Coverage Determinations (LCDs) and
Wisconsin Physician Service Legacy A LCD for Inpatient Psychiatric Services expanded to create draft for the inclusion of Legacy A and MAC A coverage.

Illinois 09/16/2009
Michigan 09/09/2009
Minnesota 09/24/2009
Wisconsin 09/25/2009
J5 MAC 10/08/2009
Open Meeting 08/19/2009

Policy published on draft website and on open meeting website for beginning of comment period 10/08/2009, policy sent to professional organizations for review and comment, sent to August 19, 2009 Open Meeting and then through CAC process although Medicare Part B not included in policy.

10/08/2009

11/23/2009

03/18/2010

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04/19/2010 €”In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor  Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor   Palmetto.

8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Trailblazers (04901)

02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).

03/18/2010