Billing and Coding: Psychiatric Inpatient Hospitalization

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34183-Psychiatric Inpatient
Hospitalization.



**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.



**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)



**General Documentation Requirements:**  
  
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.  
  
The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.  
  
**Inpatient Psychiatric Facility Services Certification and Recertification
Requirements:**  
  
 _ _The requirements for physician certification and recertification for
inpatient psychiatric facility services are similar to the requirements for
certification and recertification for inpatient hospital services. However,
there is an additional certification requirement. 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.  
  
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 hospital's utilization review committee (on a
case-by-case basis), but no less frequently than every 30 days.  
  
There is also a difference in the content of the certification and
recertification statements. 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:  
  

    1. Treatment which could reasonably be expected to improve the patient's condition;   
  

    2. Diagnostic study;
    3. 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   
  

    4. 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.

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)  
  
 **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, the documentation in the initial psychiatric
evaluation should include, whenever available, the following items:

  1. Patient's chief complaint;
  2. Description of acute illness or exacerbation of chronic illness requiring admission;
  3. Current medical history, including medications and evidence of failure at or inability to benefit from a less intensive, outpatient program;
  4. Past psychiatric and medical history;
  5. History of substance abuse;
  6. Family, vocational and social history;
  7. 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 of daily living (ADLs);
  8. Physical examination;
  9. Formulation of the patient's status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the psychiatric inpatient hospitalization services; and
  10. _ICD-10-CM/_ DSM-IV-TRTM diagnoses, including all five axes of the multiaxial assessment as described in the DSM-IV-TRTM. A team approach may be used in developing the initial psychiatric evaluation and the plan of treatment (see "Plan 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:

    * The types of psychiatric and medical therapy services and medications;
    * Laboratory and other diagnostic testing;
    * Allergies;
    * Provisional diagnosis(es); and
    * 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. Although the Plan of Treatment
is a requirement, the format and specific items to be included are up to the
provider. Documentation of the parameters below is suggested to support the
medical necessity for the inpatient services throughout the patient's stay.  
  

      * This individualized, comprehensive, outcome-oriented plan of treatment should be developed:  

        1. within the first three (3) program days after admission;
        2. by the physician, the multidisciplinary treatment team, and the patient; and should be
        3. based upon the problems identified in the physician's diagnostic evaluation, psychosocial and nursing assessments.
        4. The treatment plan should include:  

          1. the specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished;
          2. the expected outcome for each problem addressed; and
          3. contain outcomes that are measurable, functional, time-framed, and directly related to the cause of the patient's admission.
          4. 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.  
  

          5. 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. Each progress note should be legible, dated and signed,
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:**  
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.  
  
Not applicable  
  
Not applicable