evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
 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.
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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).    Reporting and recordkeeping requirements . All IPFs participating in the IPF PPS must meet the recordkeeping and cost reporting requirements as specified in 42 CFR 412.27(c), 413.20, 413.24, and 482.61.  Medical record requirements are detailed in section 30 of this chapter.    An IPF may not fil e its cost reports as an all -inclusive provider unless that all - inclusive status has been previously approved by its Medicare Administrative  Contractor, in accordance with the Provider Reimbursement Manual, Part 1,  chapter 22, section 2208.    20 - Admission Requirements (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with  42 CFR 412.27( c), for all IPFs, a provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnosis of comorbid conditions  as well as the psychiatric diagnosis.  The reasons for admission must be clearly documented as stated by the patient or others significantly involved, or both.  Psychiatric hospitals are required to be primarily engaged in providing, by or under the supervision of a psychiatrist, psychiatric services for the diagnosis and treatment of mentally ill pe rsons, according to 42 CFR 412.23(a).  Distinct  part psychiatric units of acute care hospitals and CAHs are required to admit only those patients whose admission to the unit is required for active treatment, of an intensity that can be provided appropriate ly only in an inpatient hospital setting, of a psychiatric principal diagnosis that is listed in the  International Classification of Diseases, Tenth Revision, Clinical Modification .        As a condition for Medicare payment, all admissions to IPFs must be  certified and recertified by a physician, as detailed in section 30.2.1.  30 - Medical Records Requirements  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  The medical records maintained by an IPF must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution.
(Medicare Benefit Policy Manual)
The medical records maintained by an IPF must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution.  In addition, consistent with the hospital conditions of participation, all medical records, including progress notes and treatment plan, sho uld 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 service furnished.   30.1 - Development of Assessment/Diagnostic Data  (Rev. 2 53, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(c) and 42 CFR 482.61(a), m edical  records must stress the psychiatric components of the record, including history of findings and treatment provided for  the psychiatric condition for which the patient is hospitalized.   (1)  The identification data must include the patients legal status.  According to the Interpretative Guidelines for 482.61(a)(1) given in the State Operations Manual (SOM; see IOM 100-07, Appendix AA) , legal status is defined in the State statutes and dictates the circumstances under which the patient was admitted and/or is being treated - i.e., voluntary, involuntary, committed by court, evaluation and recertification are in accordance with State requirements.   (2)  A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnoses of comorbid conditions  as well as the psychiatric diagnoses.   (3)  The reasons for admission must be cl early documented as stated by the patient and/or others significantly involved.   (4)  The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.   (5)  When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.   30.2 - Psychiatric Evaluation  (Rev. 253, Issued: 12-  14-18, Effective: 0 1-16-19, Implementation: 01 - 16-19)  In accordance with 42 CFR 412.27(c) and 42 CFR 482.61(b), e ach patient must receive a psychiatric evaluation that must
(Medicare Benefit Policy Manual)
In accordance with 42 CFR 412.27(c) and 42 CFR 482.61(b), e ach patient must receive a psychiatric evaluation that must   (1)  Be completed within 60 hours of admission;   (2)  Include a medical history;   (3)  Contain a record of mental status;   (4)  Note the onset of illness and the circumstances leading to admission;   (5)  Describe attitudes and behavior;   (6)  Estimate intellectual functioning, memory functioning, and orientation; and   (7)  Include an inventory of the  patients assets in descriptive, not interpretative fashion.   30.2.1 - Certification and Recertification Requirements (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  Medicare Part A pays for inpatient services in an inpatient psychiatric facility only if a physician certifies and recertifies the need for services consistent with the requirements given in Pub. 100- 01, Medicare General Information, Eligibility and Entitl ement Manual, chapter 4, 10.9, for certification requirements.   The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility.  No specific procedures or forms are required.  The provider may adopt any method that permits verification of all the IPFs requirements to continue treatment.  For example, the recertification may be entered on provider generated forms, in progress notes, or in the records (relating to the stay in question)  and must be signed by a physician.   Claim denials may not be made for failure to use a certification or recertification form or failure to use particular language or format, provided that the medical record demonstrates the content requirements given at  30.2.1 are met.   30.2.1.1 - Certification  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  The certification  period begins with the order for inpatient admission.  The content requirements of the certification differ from those for other hospitals because the care furnished in inpatient psychiatric facilities is often purely custodial and thus not covered under Medicare.  The purpose of the statements, therefore, is to help ensure that Medicare pays only for services of the typ e appropriate for Medicare coverage.
(Medicare Benefit Policy Manual)
The certification that a physician must provide, with respect to IPF services, is documentation that the services furnished can reasonably be expected to improve the patient's condition or for diagnostic study.  The c ertification is required at the time of admission or as soon thereafter that is reasonable and practicable.    30.2.1.2 - Recertification  (Rev. 253, Issued: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  If the patient continues to require  active inpatient psychiatric treatment, then a physician must recertify as of the 12th day of hospitalization (with subsequent recertifications required at intervals established by the IPFs Utilization Review committee on a case -by-case basis, but no less frequently than every 30 days) that the services were and continue to be required for treatment that could reasonably be expected to improve the patients condition, or for diagnostic study, and that the patient continues to need, on a daily basis, active treatment furnished directly by , or requiring the supervision of , inpatient psychiatric facility personnel.  In addition, the hospital records should show that services furnished were intensive treatment services, admission or related services necessary f or diagnostic study , or equivalent services.  See Pub.100- 01, Medicare General Information, Eligibility and Entitlement Manual, chapter 4, 10.9, for recertification requirements.  30.2.1.3 - Delayed/Lapsed Certification and Recertification  (Rev. 253, Issu ed: 12-  14-18, Effective: 01- 16-19, Implementation: 01 - 16-19)  IPFs are expected to obtain timely certifications and recertifications.  However, delayed certifications and recertifications will be honored where, for instance, there has been an oversight or lapse, and a legitimate reason for the delay as noted in Pub. 100- 01, chapter 4, 10.9.1 and 20.1.  Denial of payment for lack of the required certification and recertification is considered a technical denial, which means a statutory  requirement has not been met.  Consequently, if an appropriate certification is later produced, the denial shall be overturned.  Reopenings of technical denial decisions may be initiated by the contractor or the provider.
(Medicare Benefit Policy Manual)
In addition to compliance with t he appropriate certification and recertification content requirements, delayed certification and recertification must include an explanation for the delay and any medical or other evidence which the IPF considers relevant for purposes of explaining the del ay.  The IPF will determine the format of the delayed certifications and recertifications, and the method by which they are obtained.  A delayed certification may be included with one or more recertifications on a single signed document.  Separate signed documents for each delayed certification and recertification are not required as they would be if timely certification and recertification had been completed.  For all IPF services, a delayed certification may not extend past discharge.  IPF certification o r recertification documentation may only be signed by a physician.   30.2.2 - Active Treatment  (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  Payment for IPF services is to be made only for "active treatment" that can reasonably  be expected to improve the patient's condition.  To assure that payment is made only under such circumstances, the law includes certain requirements that must be met before the services furnished in an IPF can be covered, including medical necessity and certification.   30.2.2.1 - Principles for Evaluating a Period of Active Treatment (Rev. 59, Issued: 11- 09-06, Effective: 01- 01-05, Implementation: 12 -04-06)  In the context of IPF services, emphasis is placed on the presence of active treatment and, therefore, this determination is the crucial one.  Simply applying the skilled care definition for general hospitals is not sufficient for determining whether payment may be made since that definition does not take into account the  patient's potential for improvement nor was it designed to permit the more sophisticated judgments required by the concept of active treatment.  For services in an IPF to be designated as active treatment, they must be:    Provided under an individualized t reatment or diagnostic plan;    Reasonably expected to improve the patient's condition or for the purpose of diagnosis; and    Supervised and evaluated by a physician.
(Medicare Benefit Policy Manual)
 Provided under an individualized t reatment or diagnostic plan;    Reasonably expected to improve the patient's condition or for the purpose of diagnosis; and    Supervised and evaluated by a physician.   Such factors as diagnosis, length of hospitalization, and the degree of functional limitation, while useful as general indicators of the kind of care most likely being furnished in a given situation, are not controlling in deciding whether the care was active treatment.  Refer to 42 CFR 482.61 , Conditions of Participation for Hospitals, for a full description of what constitutes active treatment.   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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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)