Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57052)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.  NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following Centers for Medicare and Medicaid Services (CMS) sources:Title XVIII of the Social Security Act (SSA):Section 1812(a)(1) Inpatient hospital services defined.Section 1812(b)(3) Lifetime limit of 190 days for inpatient psychiatric benefit days.Section 1814(4) Medical Records document that services were furnished while the individual was receiving intensive treatment, admission and related services for a diagnostic study, or equivalent services requirement.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1835(a) Physician certification as a requirement.Section 1861(a), 1861(c), and 1861(f) "Spell of illness", "inpatient psychiatric hospital services",  "psychiatric hospital", "medical and other health services" defined.Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Code of Federal Regulations:42 CFR Section 409.62 describes the lifetime maximum on inpatient psychiatric care.42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).42 CFR Section 411.4(a) states that the Medicare Program does not pay for services if the beneficiary has no legal obligation to pay.42 CFR Section 411.8(a) states that the Medicare Program does not pay for services if the services are paid for directly or indirectly by a governmental entity.CMS Publications:CMS Publication 100-01,Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4:10 Certification and Recertification by Physicians for Hospital Services - General10.1 Failure to Certify or Recertify for Hospital Services10.2 Who May Sign Certification or Recertification10.4 Inpatient Hospital Services Certification and Recertification10.5 Selection by Hospital of Format and Method for Obtaining Statement10.9 Inpatient Psychiatric Facility Hospital Services Certification and Recertification10.20.2 Timing for Certification and Recertification for a Beneficiary Admitted Before EntitlementCMS Publication 100-01,Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5:20.3 Psychiatric Hospital20.4 Certification of Parts of Institutions as a Psychiatric Hospital20.5 Part of a Psychiatric Institution as a Psychiatric Hospital20.6 General Hospital Facility of Psychiatric Hospital20.7 Part of a General Hospital as a Psychiatric HospitalCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 210 Inpatient Psychiatric Facility Services10.1 Background10.2 Statutory Requirements10.3 Affected Medicare Providers20 Admission Requirements30 Medical Records Requirements30.1 Development of Assessment/Diagnostic Data30.2 Psychiatric Evaluation30.2.1 Certification and Recertification Requirements30.2.1.1 Certification30.2.1.2 Recertification30.2.2 Active Treatment30.2.2.1 Principles for Evaluating a Period of Active Treatment30.2.3 Services Supervised and Evaluated by a Physician30.3 Treatment Plan30.3.1 Individualized Treatment or Diagnostic Plan30.3.2 Services Expected to Improve the Condition or for Purpose of Diagnosis30.4 Recording Progress30.5 Discharge Planning and Discharge Summary40 Personnel Requirements40.1 Director of Inpatient Psychiatric Services; Medical Staff40.2 Nursing Services50 Psychological Services60 Social Services70 Therapeutic Activities80 Benefit Application90 Benefits ExhaustCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 4:10 Inpatient Psychiatric Benefit Days Reduction10.1 Patient Status on Day of Entitlement10.2 Institution's Status in Determining Days Deducted20 Days of Admission, Discharge, and Leave30 Reduction for Psychiatric Services in General Hospitals40 Determining Days Available50 Inpatient Psychiatric Hospital Services  Lifetime LimitationCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 16:50.3.1Application of Exclusion to State and Local Government ProvidersCMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1:30.4 Electrosleep Therapy30.5 Transcendental Meditation70.1 Consultations with a Beneficiary's Family and Associates130.1 Inpatient Hospital Stays for the Treatment of Alcoholism130.3 Chemical Aversion Therapy for Treatment of Alcoholism130.4 Electrical Aversion Therapy for Treatment of Alcoholism (Electroversion Therapy, Electro-shock Therapy, Noxious Faradic Stimulation)130.6 Treatment of Drug Abuse (Chemical Dependency)130.8 Hemodialysis for Treatment of Schizophrenia160.25 Multiple Electroconvulsive therapy (MECT)230.4 Diagnosis and Treatment of ImpotenceCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 1:10.4 Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal AuthorityCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 3:30.1 Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part UnitsCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 29:230 Where to Appeal and Initial DeterminationsArticle TextThis 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 GuidelinesAn 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 RequirementsThe patients 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 historyResults of pertinent tests/proceduresSigned 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 hospitals 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:That inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:Treatment which could reasonably be expected to improve the patient's condition;Diagnostic study;The hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services, andEffective 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: