(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 2 - Inpatient Psychiatric Hospital Services  Table of Contents  (Rev. 253, 12-14-18)  Transmittals for Chapter 2   10 - Inpatient Psychiatric Facility Services  10.1 - Background 10.2 - Statutory Requirements  10.3 - Affected Medicare Providers  10.4 - Conditions for Payment under the IPF Prospective Payment System  20 - Admission Requirements  30 - Medical Records Requirements 30.1 - Development of Assessment/Diagnositic Data  30.2 - Psychiatric Evaluation  30.2.1 - Certification and  Recertification Requirements  30.2.1.1 - Certification  30.2.1.2 - Recertification  30.2.1.3 -  Delayed/Lapsed Certification and Recertification  30.2.2 - Active Treatment  30.2.2.1 - Principals for Evaluating a Period of Active Treatment  30.2.3 - Services Supervised and Evaluated by a Physician  30.3 - Treatment Plan  30.3.1 - Individualized Treatment or Diagnostic Plan 30.3.2 - Services Expected to Improve the Condition or for Purpose of Diagnosis  30.4 - Recording Progress  30.5 - Discharge Planning and Discharge Summary  40 - Personnel Requirements  40.1 - Director of Inpatient Psychiatric Services; Medical Staff 40.2 - Nursing Services  50 - Psychological Services  60 - Social Services  70 - Therapeutic Activities 80 - Benefit Limits in Psychiatric Hospitals   90 - Benefits Exhaust  10 - Inpatient Psychiatric Facility Services (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  10.1  Background (Rev. 253, Issued: 1 2- 14-18, Effective: 01- 16-19, Implementation: 01 - 16-19) This section and its subsections provide instructions about the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).  The IPF PPS replaced the reasonable cost/Tax Equity and Fiscal Responsibility Act (TEFRA) based payments subject to TEFRA limits under 1886 (b)  of the Social Security Act (the Act) for discharges beginning on and after the first day of the IPFs first cost reporting period beginning on or after January 1, 2005.  The IPF PPS, codified at 42 CFR 412 , Subpart N, provides payment for inpatient psychiatric treatment when provided to a patient in psychiatric hospitals, and distinct part psychiatric units of acute care hospitals and critical access hospitals (CAHs).  Psychiatric hospitals and psychiatric units that used to be paid reasonable -cost under TEFRA, 1886(b) of the Act, are now paid under the IPF PPS.  As described in 42 CFR 412.23(a), a psychiatric hospital must meet the following requirements to be excluded from the Inpatient Prospective Payment System (IPPS) and paid under the IPF PPS:  (1) Be primarily engaged in providing, by or under the supervision of a psychiatrist, psychiatric services for the diagnosis and treatment of mentally ill persons; and (2) Meet the conditions of participation for hospitals and special conditions of participation for psychiatric hospitals set forth in 42 CFR part 482.   As described in 42 CFR 412.27, a psychiatric unit must meet the following requirements to be excluded from the IPPS payment system, and paid under the IPF PPS:  (1) Admit only patients whose admission to the unit is required for active treatment, of an intensity that can be provided appropriately only in an inpatient hospital setting, of a psychiatric principal diagnosis that is listed in the International Classification of Diseases, Ten th Revision, Clinical Modification.  (2) Furnish, through the use of qualified personnel, psychological services, social work services, psychiatric nursing, and therapeutic activities.  (3) Maintain medical records that permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the unit, and that meet the requirements given in section 30 of this chapter.   (4) Meet special staff requirements in that the unit must have adequate numbers of qualified professional and supportive staff to evaluate inpatients, formulate written, individualized, comprehensive treatment plans, provide active treatment measures and engage in discharge planning, as given in section 40 of this chapter.   The term "inpatient psychiatric facility services" means inpatient hospital services furnished to a patient of an inpatient psychiatric facility.  IPFs are certified under Medicare as inpatient psychiatric hospitals and distinct psychiatric units of acute care hospitals and C AHs.  . 10.2 - Statutory Requirements  (Rev. 253, Issued: 1 2- 14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  Section 124 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) ( Pub. L.106- 113), mandated that the Secretary -(1) develop a per diem PPS for inpatient hospital services furnished in psychiatric hospitals and psychiatric units; (2) include in the PPS an adequate patient classification system that reflects the differences in patient resource use and costs among psychiatric hospitals and psychiatric units; (3) maintain budget neutrality; (4) is permitted  to require psychiatric hospitals and psychiatric units to submit information necessary for the development of the PPS; a nd (5) submit a report to the Congress describing the development of the PPS.  Section 124 of the BBRA also required that the IPF PPS be implemented for cost reporting periods beginning on or after October 1, 2002. The Medicare Prescription Drug, Improveme nt, and Modernization Act of 2003 (MMA) (Pub. L. 108- 173), section 405(g) authorized extend ing the IPF PPS to distinct part psychiatric units of CAHs, effective for cost reporting periods beginning on or after October 1, 2004.  10.3 - Affected Medicare Pro viders  (Rev. 253, Issued: 1 2- 14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  IPFs are certified under Medicare as inpatient psychiatric hospitals, which means, an institution that is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill patie nts, maintains clinical records necessary to determine the degree and intensity of the treatment provided to the mentally ill patient, and meets staffing requirements sufficient to carry out active programs of treatment for individuals who are furnished ca re in the institution.  A distinct part psychiatric unit may also be certified if it meets the clinical record and staffing requirements in 42 CFR 412.27 .   The regulations at 42 CFR 412.402  define an IPF as a hospital that m eets the requirements specified in 42 CFR 412.22 and 42 CFR412.23(a) , 42 CFR 482.60, 42 CFR 482.61 , and 42 CFR 482.62, and a unit that meet s the requirements specified in 42 CFR 412.22 , 42 CFR 412.25 , and 42 CFR 412.27 .  The IPF PPS does not change the basic criteria for a hospital or hospital unit to be classified as a psychiatric hospital or psychiatric unit that is excluded from the hospital prospective payment systems under 1886(d)  and 1886(g) of the Act, nor does it revise the survey and certification procedures applicable to entities seeking this classification.   The provider number ranges (Online Survey and Certification and Reporting System (OSCAR) number) for IPFs are from xx -4000 through xx- 4499, xx- Sxxx, and xx- Mxxx.    The following hospitals are not included in IPF PPS.   Veterans Administration hospitals; s ee 42 CFR 412.22 (c) .   Hospitals that are reimbursed under state cost control systems approved under 42 CFR Part 403 ; Psychiatric hospitals (provider numbers xx -4000 -  xx-4499) in the State of Maryland are paid under the IPF PPS.  Psychiatric distinct part units located in an acute care hospital in Maryland identified by S in the th ird position of the OSCAR number are waived from the IPF PPS, as are the acute hospital in which they are located.  Currently there are no CAHs in Maryland.    Hospitals that are reimbursed in accordance with demonstration projects authorized under 42 CFR 402(a)  of Pub.L. 90- 248 (42 U. S. C. 1395b- 1) or 222(a) of Pub.L. 92- 603 (42 U. S. C. 1395b- 1); IPFs in acute care hospitals that are paid in accordance with demonstration projects are paid in accordance with the demonstration project;    Nonparticipating hospitals furnishing emergency services to Medicare beneficiaries. See 42 CFR 412.22(c ). Payments to foreign hospitals are made in accordance with the provisions set forth in 42 CFR 413.74 .  10.4 - Conditions for payment under the IPF Prospective Payment System  (Rev. 253, Issued: 1 2- 14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  As required in 42 CFR 412.404, effective for cost reporting periods beginning on or after January 1, 2005, an inpatient psychiatric facility (IPF), defined as an inpatient psychiatric hospital or distinct psychiatric unit of an acute care hospital or CAH, must meet the fol lowing conditions to receive payment under the IPF prospective payment system (PPS) for inpatient hospital services furnished to Medicare Part A fee- for-service beneficiaries.  If an IPF fails to comply fully with these conditions, CMS may, as appropriate withhold (in full or in part) or reduce Medicare payment to the IPF until the facility provides adequate assurances of compliance, or CMS may classify the IPF as an inpatient hospital that is subject to the requirements for hospitals and paid under the hos pital Inpatient Prospective Payment System.   IPFs subject to the IPF PPS .  Subject to the special payment provisions of 412.22(c), an IPF must meet the general criteria set forth in 412.22.  In order to be excluded from the hospital inpatient prospective payment system as specified in 412.1(a)(1), a psychiatric hospital must meet the criteria set forth in 412.23(a), 482.60, 482.61, and 482.62 and psychiatric units must meet the criteria set forth in 412.25 and 412.27.   Limitations on charges to benefi ciaries o Prohibited charges. Except as permitted below, an IPF may not charge a beneficiary for any services for which payment is made by Medicare, even if the facility's cost of furnishing services to that beneficiary is greater than the amount the facilit y is paid under the IPF PPS. o Permitted charges.  An IPF receiving payment under the IPF PPS for a covered hospital stay (that is, a stay that included at least one covered day) may charge the Medicare beneficiary or other person only the applicable deductib le and coinsurance amounts under 42 CFR 409.82, 409.83, and 409.87 and for items or services as specified under 42 CFR 489.20(a).    Furnishing of inpatient hospital services directly or under arrangement .   Subject to the provisions of 412.422, the appl icable payments made under the IPF PPS are payment in full for all inpatient hospital services, as specified in 409.10. Hospital inpatient services do not include the following:  (a) Physicians' services that meet the requirements of 42 CFR 415.102(a) for payment on a fee schedule basis.  (b) Physician assistant services, as specified in section 1861(s)(2)(K)(i) of the Act.  (c) Nurse practitioners and clinical nurse specialist services, as specified in section 1861(s)(2)(K)(ii) of the Act. (d) Certified nurse midwife services, as specified in section 1861(gg) of the Act.  (e) Qualified psychologist services, as specified in section 1861(ii) of the Act. (f) Services of a certified registered nurse anesthetist, as specified in section 1861(bb) of the Act and defined in 42 CFR 410.69. o CMS does not pay providers or suppliers, other than IPFs, for services furnished to a Medicare beneficiary who is an inpatient of the IPF, except for the professional services described in (a) through (f) above.  o The IPF must fur nish all necessary covered services to a Medicare beneficiary who is an inpatient of the IPF, either directly or under arrangements (as specified in 42 CFR 409.3).