(Medicare Benefit Policy Manual)

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 facility services were provided because of the individual's need for active treatment (not just the days on which specific therapeutic or diagnostic servi ces are 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 follow -up 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  the patient is getting active treatment.  For example, medical supervision of a patient may be necessary to assure the early detection of significant changes in his/her 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 that ordinarily result i n progressive physical and/or mental deterioration.  Although patients with such diagnosis will most commonly be receiving custodial care, they may also receive services that meet the program's definition of active treatment (e.g., where a patient with Alz heimer's disease 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.   30.2.3 - Services Supervised and Evaluated by a Physician  (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  The types of services which meet the above requirements would include not only psychotherapy, drug therapy, and electroconvulsive therapy, but also such therapeutic activities as occupational therapy, recreational therapy, and milieu therapy, provided the therapeutic activities are expected to result in improvement in the patient's condition.  If 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 therapeutic activities 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 addition, the administration of antidepressant or tranquilizing drugs t hat are expected to significantly alleviate a patient's psychotic or neurotic symptoms would be termed active treatment (assuming that the other elements of the definitions are met).  However, the administration of a drug or drugs does not necessarily cons titute active treatment.   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 psychiatric 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 patie nt 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 per week.   When the physician periodically evaluates the therapeutic p rogram 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 the medical record and the physician's periodic conversations with the patient), active treatment would be indicated.  A finding that a patient is not receiving active treatment will not in itself preclude payment for physicians' services under Medicare Part B.  As long as th e 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.   30.3 - Treatment Plan  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  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 thoroug h evaluation of the patient's - strengths and disabilities.   The plan of treatment must be recorded in the patient's medical record in accordance with 42 CFR 412.27(c)(3) and the  Conditions of Participation for Hospitals in 42 CFR 482.61 .  30.3.1 - Individualized Treatment or Diagnostic Plan (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(c)(3) and 42 CFR 482.61(c), e ach patient must have an individual comprehensive treatment plan that must be based on an inventory of the patients strengths and disabilities.  The written plan must include   (1)  A substantiated diagnosis ;  (2)  Short -term and long- range goals;   (3)  The specific treatment modalities utilized;   (4)  The responsibilities of each member of the treatment team; and   (5)  Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.   The treatment furnished to the patient should be documented in the medical record in such a manner and with such frequency as to assure that all active therapeutic efforts are included.  The documentation should  provide a full pict ure of the therapy administered and an assessment of the patient's reaction to it.   30.3.2 - Services Expected to Improve the Condition or for Purpose of Diagnosis  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance  with 42 CFR 424.14(b)(1) and 42 CFR 424.14(c)(1), the physician must include in all certifications and recertifications that t he services provided could reasonably be expected to improve the patient's condition or are 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 psycho tic or neurotic symptoms that necessitated hospitalization and improve the patient's level of functioning.   30.4 - Recording Progress  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(c)(4) and 42 CFR 482.61(d), progress notes must be recorded by the doctor of medicine or osteopathy responsible for the care of the patient as specified in  482.12(c), by a nurse, social worker and, when appropriate, others significantly involved in active treatment modalities.  The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first two months and at least once a month thereafter and must contain recommendations for revisions in the treatment p lan as indicated as well as precise assessment of the patients progress in accordance with the original or revised treatment plan.   As outlined above in 30 of this chapter, consistent with sound clinical practice (and the hospital conditions of participation at 482.24(c)(1)) , all medical records, including progress notes, should be legible and complete, and should be promptly signed and dated by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the se rvice furnished.   30.5 - Discharge Planning and Discharge Summary (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(c)(5) and 482.61(e), t he record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patients hospitalization and recommendations from appropriate services concerning follow -up or aftercare as well as a brief summary of the patients condition on discharge.   40 - Personnel Requirements  (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  IPFs must have adequate numbers of qualified professional and supportive staff, according to 42 CFR 412.27 and 42 CFR 482.62 .  IPFs must employ or undertake to provide a dequate numbers of qualified professional, technical, and consultative personnel to:   (1)  Evaluate patients;   (2)  Formulate written individualized, comprehensive treatment plans;   (3)  Provide active treatment measures; and   (4)  Engage in discharge pla nning.   Doctors of medicine or osteopathy and other appropriate professional personnel must be available to provide necessary medical and surgical diagnostic and treatment services.  If medical and surgical diagnostic and treatment services are not availab le within the institution, the institution must have an agreement with an outside source of these services to ensure that they are immediately available or a satisfactory agreement must be established for transferring patients to a general hospital that pa rticipates in the Medicare program.  40.1 - Director of Inpatient Psychiatric Services; Medical Staff  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(d)(2) and 42 CFR 482.62(b), inpatient psychiatric services must be under the supervision of a clinical director, service chief, or equivalent who is qualified to provide the leadership required for an intensive treatment program.  The number and qualifications of doctors of medicine and osteopathy must be adequate to provide essential psychiatric services.    (1)  The clinical director, service chief, or equivalent must meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.   (2)  The director must monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff.   40.2 - Nursing Services  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(d)(3) and 42 CFR 482.62(d), IPFs must have a qualified director of psychiatric nursing services.  In addition to the director of nursing, there must be adequate numbers of registered nu rses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patients active treatment program and to maintain progress notes on each patient.    (1)  The director of psychiatric nursing services must be a registe red nurse who has a masters degree in psychiatric or mental health nursing, or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill.  The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.    (2)  The staffing pattern must e nsure  the availability of a registered nurse 24 hours each day.  There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary  under each patients active treatment program.   50 - Psychological Services  (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  The IPF must provide or have available psychological services to meet the needs of the patients.  The services must be furnished in accordance with acceptabl e standards of practice, service objectives, and established policies and procedures, according to 42 CFR 412.27  and 42 CFR 482.62 .  60 - Social Services  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)