evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
(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)
(Medicare Benefit Policy Manual)
60 - Social Services  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27 and 42 CFR 482.62 , there must be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished.  The services must be furnished in accordance with accept ed standards of practice and established policies and procedures..   1.  The director of the social work department or service must have a Masters degree from an accredited school of social work or must be qualified by education and experience in the social services needs of the mentally ill.  If the director does not hold a Masters degree in social work, at least one staff member must have this qualification.   2.  Social service staff responsibilities must include, but are not limited to, participating in  discharge planning, arranging for follow -up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital.  70 - Therapeutic Activities  (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  According to 42 CFR 412.27 and 42 CFR 482.62  IPFs  must provide a therapeutic activities program.    (1)  The program must be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels o f physical and psychosocial functioning.    (2)  The number of qualified therapists, support personnel, and consultants must be adequate to provide comprehensive therapeutic activities consistent with each patients active treatment program.   80 - Benefit Limits in Psychiatric Hospitals  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  The psychiatric benefit application (190 days) applies to freestanding psychiatric hospitals per 42 CFR 409.62 .  The 190- lifetime limitation does not apply to certified psychiatric distinct part units.  Section 409.62 states, There is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary.  Therefore, once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are availabl e to that individual.
(Medicare Benefit Policy Manual)
90 - Benefits Exhaust  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  Effective December 3, 2007, for payment purposes, an IPF discharge occurs when benefits exhaust , and the benefits exhaust date will  substitute for the discharge date.  The claim will be paid either on the discharge date if the benefits are available or on benefit exhaust date if the discharge is after the benefits exhaust date.  When the services actually are provided, the PRICER vers ion used to price claims for the time will be used.  No pay/110 TOBs are allowed instead of continually adjusting the claims (117 TOB) until actual discharge occurs once benefits exhaust.   Under the Tax Equity and Fiscal Responsibility Act (TEFRA), the Provider Statistical and Reimbursement (PS&R) report used the benefits exhaust date as the discharge date.  This changed when the IPF PPS was implemented, and the 'actual' discharge date was used.  The days stay with the year they occurred, making it easier f or the PS&R report (especially during the blend period) to settle the cost report.  This means that:   1. Claims will be settled on the appropriate cost report;   2. The appropriate PPS -TEFRA blend percentage will be paid;   3. Patients with long lengths of s tay will be counted on the correct PS&R report; and  4. The PRICER version used will be the one in effect at the time the services were provided.
(Medicare Benefit Policy Manual)
3. Patients with long lengths of s tay will be counted on the correct PS&R report; and  4. The PRICER version used will be the one in effect at the time the services were provided.                       Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R253BP  12/14/2018  Updates to the Inpatient Psychiatric Facility Benefit Policy Manual  01/16/2019  11062 R223BP  05/13/2016  Clarification of Inpatient Psychiatric Facilities (IPF) Requirements for Certification, Recertification and Delayed/Lapsed Certification and Recertification  08/15/2016  9522 R194BP  09/03/2014  Pub. 100- 02 Language -Only Update for ICD- 10 Upon Implementation of ICD -10 8605 R181BP  03/14/2014  Pub. 100- 02 Language -Only Update for ICD- 10  Rescinded and replaced by Transmittal 194  10/01/2014  8605 R69BP  04/27/2007  Change to the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) Discharge Bill  12/03/2007  5474 R59BP  11/09/2006  Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)  12/04/2006  5287 R56BP  11/03/2006  Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)  12/04/2006  5287 R1BP  10/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 3 - Duration of Covered Inpatient Services   Table of Contents  (Rev. 261;  Issued: 10 -04-19)   Transmittals for Chapter 3  Crosswalk to Old Manual  10 - Benefit Period (Spell of Illness)  20 - Inpatient Benefit Days  20.1 -  Counting Inpatient Days  20.1.1 -  Late Discharge  20.1.2 -  Leave of Absence 20.1.3 -  Discharge or Death on First Day of Entitlement or Participation  30 - Inpatient Days Counting Toward Benefit Maximums  10 - Benefit Period (Spell of Illness)  (Rev.  261, Issued_10- 04-19, Effective: 11- 05-19, Implementation: 11- 05-19) A3-3035, HO -215  A Benefit period is a period of consecutive days during which medical benefits for covered services, with certain specified maximum limitations, are available to the beneficiary.  Under Part A, 60 full days of hospitalization plus 30 coinsurance days represent the maximum benefit period.  The benefit period is renewed when the beneficiary has not been an inpatient of a hospital or of a SNF (see 20.B) for 60 consecutive days.  Refer to Pub.100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductible, Coinsurance Amounts, and Payment Limitations for additional information on benefit periods.  20 - Inpatient Benefit Days  (Rev. 261, Issued_10- 04-19, Effective: 11- 05-19, Implementation: 11- 05-19) A3-3103, A3- 3135, HO -216, SNF -242  A.  Inpatient Hospital Benefit Days   A patient having hospital insurance coverage is entitled, subject to the inpatient deductible and coinsurance requirements, to have payment made on his/her behalf for up to 90 days of covered inpatient hospital services in each benefit period.  Also, the patient has a lifetime reserve of 60 additional days (see Chapter 5, 10 ).  B.  Posthospital Extended Care Days
(Medicare Benefit Policy Manual)
B.  Posthospital Extended Care Days   A patient having hospital insurance coverage is entitled (subject to the coinsurance requirements described in detail in Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations) to have payment made on his/her behalf for up to 100 days of covered inpatient extended care services in each benefit period.   Refer to Pub. 100- 01, Medicare General Information, Eli gibility, and Entitlement Manual, Chapter 3, 10.4.4 for the definition of SNF inpatient for benefit period purposes.    20.1 - Counting Inpatient Days  (Rev. 1, 10- 01-03) A3-3103.1, A3- 3104.3, A3- 3135.1, HO -217.3, HO -216.1, SNF -242.1   The number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days.  A day begins at midnight and ends 24 hours later.  The midnight -to-midnight method is to be used in counting days of care for Medicare reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purposes.   A part of a day, including the day of admission and day on which a patient returns from leave of absen ce, counts as a full day.  However, the day of discharge, death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of admission.  If admission and discharge or death occur on the same d ay, the day is considered a day of admission and counts as one inpatient day.  Charges for ancillary services on the day of discharge or death or the day on which a patient begins a leave of absence are covered.   20.1.1 - Late Discharge  (Rev. 1, 10- 01-03) A3-3103.2, A3- 3135.2, HO -216.2, SNF -242.2
(Medicare Benefit Policy Manual)
20.1.1 - Late Discharge  (Rev. 1, 10- 01-03) A3-3103.2, A3- 3135.2, HO -216.2, SNF -242.2   When a patient chooses to continue to occupy hospital or SNF accommodations beyond the checkout time for personal reasons, the hospital or SNF may charge the beneficiary for the continued stay.  Such a stay beyond the checkout time, for the comfort or convenience of the patient, is not covered under the program, and the hospital's or SNF's agreement to participate in the program does not preclude charging the patient.  However, the hospital must provide the benefic iary with an Advance Beneficiary Notice (ABN) before the noncovered services are provided.  See Medicare Claims Processing Manual, chapter 30, for instructions about ABNs.   Where the patient's medical condition is the cause of the stay past the checkout ti me (e.g., the patient needs further services, is bedridden and awaiting transportation to their home or in the case of a hospital, transfer to a skilled nursing facility, or dies in the SNF or hospital), the stay beyond the discharge hour is covered under the program and the hospital or SNF may not charge the patient.   The imposition of a late checkout charge by a hospital or SNF does not affect the counting of days for:    Ending a benefit period;    The number of days of inpatient care available to the indivi dual in a hospital or SNF; and    The 3 -day prior hospitalization requirement for coverage of post hospital extended care services and Part A home health services.   A late charge by a hospital does not affect counting of days for meeting the prior inpatient stay requirement for coverage of extended care services.   The Quality Improvement Organization is responsible for reviewing the appropriateness of early discharges.   20.1.2 - Leave of Absence  (Rev. 1, 10- 01-03) A3-3103.3, A3- 3135.3, HO -216.3, SNF -242.3
(Medicare Benefit Policy Manual)
The day on which the patient began a leave of absence is treated as a day of discharge, and is not counted as an inpatient day unless the patient returns to the facility by midnight of the same day.  The day the patient returns to the hospital or SNF from a leave of absence is treated as a day of admission and is counted as an inpatient day if the patient is present at midnight of that day.   Refer to the Medicare Claims Processing Manual, Chapter 3, Inpatient Hospital Services, or the Medicare Claims Processing Manual, Chapter 6, SNF Inpatient Billing, as appropriate, for reporting inpatient leave of absence on the Medicare claim.   20.1.3 - Discharge or Death on First Day of Entitlement or Participation  (Rev. 1, 10- 01-03) A3-3103.4, A3- 3135.4, HO -216.4, SNF -242.4   For SNF services, the cost of such services has been built into the SNF PPS base.  This makes the PPS per diem somewhat higher than it would otherwise have been for all of the preceding SNF days that Part A does cover, even though the day of  discharge itself is not a covered Part A day:    A patient is admitted prior to the first day of entitlement and dies or is discharged from a participating hospital on the first day of entitlement; or    A patient in a noncovered stay in a nonparticipating hospital dies or is discharged on the first day the hospital becomes a participating hospital.  For a late discharge on such a day, the rules in 20.1.1  will be followed.   For SNF services, Medicare does not pay for accommo dations on the day of discharge or death.  Medicare pays for ancillary services (under Part A) when a patient dies or is discharged on the first day a facility becomes a participating facility and the other requirements for coverage of extended care servic es are met.   Although a day of utilization is not counted in these situations, a benefit period begins and any charges for covered services are applied against the inpatient hospital deductible.   30 - Inpatient Days Counting Toward Benefit Maximums  (Rev. 1, 10- 01-03) A3-3107, A3- 3136, HO -216.5, SNF -244
(Medicare Benefit Policy Manual)
30 - Inpatient Days Counting Toward Benefit Maximums  (Rev. 1, 10- 01-03) A3-3107, A3- 3136, HO -216.5, SNF -244  A.  90- Day Benefit Limitation   Inpatient hospital (including psychiatric hospital) services count toward the maximum of 90 benefit days payable per benefit period only if:    Payment for the services is made;    Payment for the services would be made if a request for payment and claim were filed properly and timely, a physician certified that the services were necessary, if required, and the provider submitted all necessary evidence; or    Payment cannot be made be cause the inpatient deductible or coinsurance is higher then the charges.   B.  Lifetime Reserve Days   Part A benefits allow for 60 lifetime reserve days for use after a 90 -day benefit period has exhausted.  The 60 days are not renewable and may be used only once during a beneficiarys lifetime.  Inpatient hospital services count toward the maximum of 60 lifetime reserve days under the same conditions as in subsection A except that days are not counted if:    The individual elects not to have payment made ( See the Medicare Benefit Policy Manual, Chapter 5, Lifetime Reserve Days, 30), or    The coinsurance rate exceeds the daily charge.  (See the Medicare Benefit Policy Manual, Chapter 5, Lifetime Reserve Days, 10.2).  C.  Lifetime Inpatient Psychiatric Hosp ital Limitation   Inpatient psychiatric hospital services count toward the 190- day lifetime limitation on inpatient psychiatric hospital services only if the conditions in subsection A are met.  This limitation does not apply to inpatient psychiatric servic es furnished in a general hospital (or distinct part).   D.  Inpatient Post -hospital Extended Care Services Counting Toward Maximums   Post-hospital extended care services count toward the maximum number of benefit days payable per benefit period only if:    Payment for the services is made, or    Payment for the services would be made if a request for payment were properly filed, the physician certified that the services were medically necessary, and the provider submitted all necessary evidence.   When payment cannot be made because of the extended care coinsurance requirement, the day(s) used nevertheless count toward the beneficiary's maximum days of extended care.
(Medicare Benefit Policy Manual)
When payment cannot be made because of the extended care coinsurance requirement, the day(s) used nevertheless count toward the beneficiary's maximum days of extended care.   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R261BP  10/04/2019 Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  11/05/2019  11454  R1BP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter
(Medicare Benefit Policy Manaul)
Medicare Benefit Policy Manual  Chapter 4 - Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation  Table of Contents  (Rev. 1, 10- 01-03)  Transmittals for Chapter 4  10 - Inpatient Psychiatric Benefit Days Reduction  10.1 -  Patient Status on Day of Entitlement  10.2 -  Institution's Status in Determining Days Deducted  20 - Days of Admission, Discharge, and Leave  30 - Reduction for Psychiatric Services in General Hospitals  40 - Determining Days Available  50 - Inpatient Psychiatric Hospital Services -  Lifetime Limitation  10 - Inpatient Psychiatric Benefit Days Reduction  (Rev. 1, 10- 01-03) A3-3104, HO -217  If an individual is in a participating psychiatric hospital on the first day of the entitlement to hospital insurance, the number of inpatient benefit days in the first benefit period is subject to reduction.  The days (not necessarily consecutive) on which an individual was an inpatient of a psychiatric hospital in the 150- day period immediately before the first day of entitlement must be subtracted from the 150 days of inpatient hospital services for which he/ she would otherwise be eligible in the first benefit period.  Days spent in a general hospital for diagnosis or treatment of a psychiatric condition prior to entitlement will not reduce the patient's 150 inpatient benefit days in the initial benefit period .  After entitlement, the reduction applies not only to inpatient hospital services received in a psychiatric hospital, but also to services received in a general hospital if the individual is an inpatient of the general hospital primarily for the diagnosis or treatment of mental illness.  If a patient has no psychiatric benefit days remaining because of the reduction, Medicare payment may still be made for up to 150 days of inpatient hospital services that are not for the diagnosis and treatment of  mental illness.   EXAMPLE l:   John was admitted to a Medicare participating psychiatric hospital named Spring Psychiatric Hospital on January 20.  Johns Medicare entitlement was effective February 1 while John was still an inpatient of Spring Psychiatric Hospital.  The 12 days of inpatient psychiatric care prior to entitlement are deducted from the 150 days available in the first benefit period.  John has 138 days available in the first benefit period (150 minus 12 = 138).  EXAMPLE 2:
(Medicare Benefit Policy Manaul)
Mary was admitted to  Spring Psychiatric Hospital on January 2 and discharged January 31.  She was readmitted March 1 and discharged April 15.  Marys Medicare entitlement became effective April 1.  Mary used a total of 60 psychiatric days in the 150 day period prior to her Me dicare entitlement.  Therefore, the days available to Mary in her first benefit period are 90 days.  Pre -entitlement days used by Mary were 29 for her January admission and 31 used during her March admission prior to her entitlement April 1.  10.1 - Patien t Status on Day of Entitlement  (Rev. 1, 10- 01-03) A3-3104.1, HO -217.1  A patient in a participating psychiatric hospital on the first day of entitlement is subject to this reduction.  The reduction applies to patients admitted to or discharged from such a hospital on their first day of entitlement, or who begin or end a leave of absence on that day.  Where only a distinct part of an institution is participating as a psychiatric hospital, the provision applies only to patients who, on their first day of enti tlement, are inpatients of that part.  10.2 - Institution's Status in Determining Days Deducted  (Rev. 1, 10- 01-03) A3-3104.2, HO -217.2