MEDICARE COVERAGE SUMMARY: PSYCHIATRIC INPATIENT HOSPITALIZATION

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1 OPTUM MEDICARE COVERAGE SUMMARY: PSYCHIATIRC INPATIENT HOSPITALIZATION MEDICARE COVERAGE SUMMARY: PSYCHIATRIC INPATIENT HOSPITALIZATION Guideline Number: Effective Date: January, 2018 Table f Cntents Page INSTRUCTIONS FOR USE.1 PSYCHIATRIC INPATIENT HOSPITALIZATION....1 APPLICABLE STATES 2 COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY.. 2 CLINICAL BEST PRACTICES...4 REFERENCES...6 HISTORY/REVISION INFORMATION..6 Relevant Services Psychiatric Inpatient Hspitalizatin Related Behaviral Health Plicies & Guidelines Optum Level f Care Guidelines INSTRUCTIONS FOR USE This guideline is used t make cverage determinatins as well as t infrm discussins abut evidence-based practices and discharge planning fr behaviral health benefit plans managed by Optum 1. When deciding cverage, the member s specific benefits must be referenced. All reviewers must first identify member eligibility, the member-specific benefit plan cverage, and any federal r state regulatry requirements that supersede the member s benefits prir t using this guideline. Other clinical criteria may apply. Optum reserves the right, in its sle discretin, t mdify its clinical criteria as necessary using the prcess described in Clinical Criteria. This guideline is prvided fr infrmatinal purpses. It des nt cnstitute medical advice. Optum may als use tls develped by third parties that are intended t be used in cnnectin with the independent prfessinal medical judgment f a qualified health care prvider and d nt cnstitute the practice f medicine r medical advice. Optum may develp clinical criteria r adpt externally-develped clinical criteria that supersede this guideline when required t d s by cntract r regulatin. PSYCHIATRIC INPATIENT HOSPITALIZATION Inpatient psychiatric hspitalizatin prvides 24-hurs f daily care in a structured, intensive, and secure setting fr patients wh cannt be safely and/r adequately managed at a lwer level f care. This setting prvides daily physician (MD/DO) supervisin, 24-hur nursing/treatment team evaluatin and bservatin, diagnstic services, and psychtherapeutic and medical interventins (Centers fr Medicare and Medicaid Services, Lcal Cverage Determinatins (C MS L33624, 33975, 34183, 34570). Inpatient psychiatric care may be delivered in a psychiatric acute care unit within a psychiatric institutin, r a psychiatric inpatient unit within a general hspital (CMS L33624, 34183, 34570).a 1 Optum is a brand used by United Behaviral Health and its affiliates. Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 1 f 6

2 APPLICABLE STATES This Medicare Cverage Summary is applicable t the fllwing States/jurisdictins. CMS L33624 Cnnecticut Illinis Maine Massachusetts Minnesta New Hampshire New Yrk Rhde Island Vermnt Wiscnsin CMS L33975 Flrida Puert Ric Virgin Islands CMS L34183 Kentucky Ohi CMS L34570 Nrth Carlina Suth Carlina Virginia West Virginia If services are delivered in anther state, please apply the Optum Level f Care Guidelines. COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY Indicatins (CMS L33624, 33975, 34183, 34570) Patients admitted t inpatient psychiatric hspitalizatin must be under the care f a physician. The physician must certify/recertify the need fr inpatient psychiatric hspitalizatin. The patient must require active treatment f his/her psychiatric disrder. The patient r legal guardian must prvide written infrmed cnsent fr inpatient psychiatric hspitalizatin in accrd with state law. If the patient is subject t invluntary r curt-rdered cmmitment, the services must still meet the requirements fr medical necessity in rder t be cvered. Admissin Criteria: Intensity f Service (CMS L33624, 33975, 34183, 34570) The patient must require intensive, cmprehensive, multimdal treatment including 24 hurs per day f medical supervisin and crdinatin because f a mental disrder. The need fr 24 hurs f supervisin may be due t the need fr patient safety, psychiatric diagnstic evaluatin, ptential severe side effects f psychtrpic medicatin assciated with medical r psychiatric cmrbidities, r evaluatin f behavirs cnsistent with an acute psychiatric disrder fr which a medical cause has nt been ruled ut. The acute psychiatric cnditin being evaluated r treated by inpatient psychiatric hspitalizatin must require active treatment, including a cmbinatin f services such as intensive nursing and medical interventin, psychtherapy, ccupatinal and activity therapy. Patients must require inpatient psychiatric hspitalizatin services at levels f intensity and frequency exceeding what may be rendered in an utpatient setting, including psychiatric partial hspitalizatin. There must be evidence f failure at, inability t benefit frm, r unacceptable risk in an utpatient treatment setting. C laims fr care delivered at an inapprpriate level f intensity will be denied. Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 2 f 6

3 Fr services in an inpatient psychiatric facility t be designated as active treatment they must be: Prvided under an individualized treatment r diagnstic plan Reasnably expected t imprve the patient s cnditin r fr the purpse f diagnsis; and Supervised and evaluated by a physician. Admissin Criteria: Severity f Illness (CMS L33624, 33975, 34183, 34570) Examples f inpatient admissin criteria include (but are nt limited t): Threat t self r thers requiring 24-hur prfessinal bservatin Suicidal ideatin r gesture within 72 hurs prir t admissin. Self-mutilatin (actual r threatened) within 72 hurs prir t admissin. Chrnic and cntinuing self-destructive behavir (e.g., bulimic behavirs, substance abuse) that pses a significant and immediate threat t life, limb, r bdily functin. Assaultive behavir threatening thers within 72 hurs prir t admissin. Significant verbal threat t the safety f thers within 72 hurs prir t admissin. Cmmand hallucinatins directing harm t self r thers where there is risk f the patient taking actin n them. Acute disrdered/bizarre behavir r psychmtr agitatin r retardatin that interferes with the activities f daily living (ADLs) s that the patient cannt functin at a less intensive level f care during evaluatin and treatment. Cgnitive impairment (disrientatin r memry lss) due t an acute Axis I disrder that endangers the welfare f the patient r thers. Fr patients with a dementing disrder fr evaluatin f treatment f a psychiatric cmrbidity (e.g., risk f suicide, vilence, severe depressin) warranting inpatient admissin. A mental disrder causing majr disability in scial, interpersnal, ccupatinal, and/r educatinal functining that is leading t dangerus r life-threatening functining, and that can nly be addressed in an acute inpatient setting. A mental disrder that causes an inability t maintain, adequate nutritin r self-care, and family/cmmunity supprt cannt prvide reliable, essential care, s that the patient cannt functin at a less intensive level f care during evaluatin and treatment. Failure f utpatient psychiatric treatment s that the beneficiary requires 24-hur prfessinal bservatin and care. Reasns fr failure f utpatient treatment culd include: Increasing severity f psychiatric symptms; Nncmpliance with medicatin regiment due t the severity f psychiatric symptms; Inadequate clinical respnse t psychtrpic medicatins; Due t the severity f psychiatric symptms, the patient is unable t participate in an utpatient psychiatric treatment prgram. Nte: Fr all symptm sets r diagnses, the severity and acuity f symptms and the likelihd f respnse t treatment, cmbined with the requirement fr an intensive 24-hur level f care, are the significant factrs in determining the necessity f inpatient psychiatric treatment. Discharge Criteria: Intensity f Service (CMS L33624, 33975, 34183, 34570) Patients in inpatient psychiatric care may be discharged by stepping dwn t a less intensive level f utpatient care. Stepping dwn t a less intensive level f service than inpatient hspitalizatin wuld be cnsidered when patients are n lnger require 24-hur bservatin fr safety, diagnstic evaluatin, r treatment as described abve. These patients wuld becme utpatients, receiving either psychiatric partial hspitalizatin r individual utpatient mental health services, rendered and billed by apprpriate prviders. It may be apprpriate fr sme patients t receive an unsupervised pass t leave the hspital fr a brief perid in rder t assess their readiness fr utpatient care. Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 3 f 6

4 Discharge Criteria: Severity f Illness (CMS L33624, 33975, 34183, 34570) Patients whse clinical cnditin imprves r stabilizes, wh n lnger pse an impending threat t self r thers, and wh d nt still require 24-hur bservatin available in an inpatient psychiatric unit shuld be stepped dwn t utpatient care. Patients wh are persistently unwilling r unable t participate in active treatment f their psychiatric cnditin wuld als be apprpriate fr discharge. Limitatins (CMS L33624, 33975, 34183, 34570) Failure t prvide dcumentatin t supprt the necessity f test(s) r treatment(s) may result in denial f claims r services under Sectins 1862(a)(1)(A) and 1833 f Title XVIII f the Scial Security Act. This includes medical recrds. That dn t supprt the reasnableness and necessity f service(s) furnished; In which the dcumentatin is illegible; r Where medical necessity fr inpatient psychiatric services is nt apprpriately certified by the physician. The fllwing d nt represent reasnable and medically necessary inpatient psychiatric services and cverage is excluded under Title XVIII f the Scial Security Act, Sectin 1862(a)(1)(A): Services which are primarily scial, recreatinal r diversin activities, r custdial r respite care; Services attempting t maintain psychiatric wellness fr the chrnically mentally ill; Treatment f chrnic cnditins withut acute exacerbatin; Vcatinal training; Medical recrds that fail t dcument the required level f physician supervisin and treatment planning prcess; Electrsleep therapy; Electrical Aversin Therapy fr treatment f alchlism; Hemdialysis fr the treatment f schizphrenia; Transcendental Meditatin; Multiple Electrcnvulsive Therapy (MECT); It is nt reasnable and medically necessary t prvide inpatient psychiatric hspital services t the fllwing types f patients, and cverage is excluded under Title XVIII f the Scial Security Act, Sectin 1862(a)(1)(A): Patients wh require primarily scial, custdial, recreatinal, r respite care; CLINICAL BEST PRACTICES Patients whse clinical acuity requires less than 24 hurs f supervised care per day; Patients wh have met the criteria fr discharge frm inpatient hspitalizatin; Patients whse symptms are the result f a medical cnditin that requires a medical/surgical setting fr apprpriate treatment; Patients whse primary prblem is a physical health prblem withut a cncurrent majr psychiatric episde; Patients with alchl r substance abuse prblems wh d nt have a cmbined need fr active treatment and psychiatric care that can nly be prvided in the inpatient hspital setting; Patients fr whm admissin t a psychiatric hspital is being used as an alternative t incarceratin. At the time f admissin r as sn therafter as is reasnable and practicable, a physician (the admitting physician r a medical staff member with knwledge f the case) must certify the medical necessity fr inpatient psychiatric hspital services. The first recertificatin is required as f the 12 th day hspitalizatin. Subsequent recertificatins will be required at intervals established by the hspital s utilizatin review cmmittee (n a case-by-case basis), but n less frequently than every 30 days (CMS L33624, 33975, 34183). Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 4 f 6

5 The physician s recertificatin shuld state that inpatient psychiatric hspital services furnished since the previus certificatin r recertificatin were, and cntinue t be, medically necessary fr either: Treatment which culd be reasnably expected t imprve the patient s cnditin; Diagnstic study; The hspital recrds indicate that the services furnished were either intensive treatment services, admissin and related services necessary fr diagnstic study, r equivalent services; and A statement recertifying that the patient cntinues t need, n a daily basis, active treatment furnished directly by r requiring the supervisin f inpatient psychiatric hspital persnnel (CMS L33624, 33975, 34183, 34570). The initial psychiatric evaluatin with medical histry and physical examinatin shuld be perfrmed within 24 hurs f admissin, but in n case later than 60 hurs f admissin, in rder t establish medical necessity fr psychiatric inpatient hspitalizatin services. Dcumentatin in the initial psychiatric evaluatin shuld include, whenever available, the fllwing items: Patient s chief cmplaint; Descriptin f acute illness r exacerbatin f chrnic illness requiring admissin; Current medical histry, including medicatins and evidence f failure at r inability t benefit frm a less intensive utpatient prgram; Past psychiatric and medical histry; Histry f substance abuse; Family, vcatinal and scial histry; Mental status examinatin, including general appearance and behavir, rientatin, affect, mtr activity, thught cntent, lng and shrt term memry, estimate f intelligence, capacity fr self harm and harm t thers, insight, judgment, capacity fr activities f daily living (ADLs); Physical examinatin; Frmulatin f the patient s status, including an assessment f the reasnable expectatin that the patient will make timely and significant practical imprvement in the presenting acute symptms as a result f the psychiatric inpatient hspitalizatin services; and ICD/DSM diagnses (CMS L33624, 33975, 34183, 34570). It will nt always be pssible t btain the suggested infrmatin at the time f evaluatin. In such cases, the limited infrmatin that is btained and dcumented, must still be sufficient t supprt the need fr an inpatient level f care (CMS L33624, 33975, 34183, 34570). The individualized, cmprehensive, utcme riented plan f treatment shuld be develped: Within the first 3 prgram days after admissin; By the physician, the multidisciplinary team, and the patient, and shuld be; Based upn the prblems identified by the physician s diagnstic evaluatin, psychscial and nursing assessments (CMS L33624, 33975, 34183, 34570). The treatment plan shuld include: The specific treatments rdered, including the type, amunt, frequency, and duratin f the services t be furnished; The expected utcme fr each prblem addressed; and Cntain utcmes that are measurable, functinal, time-framed, and directly related t the cause f the patient s admissin (CMS L33624, 33975, 34183, 34570). Treatment plan updates shuld shw the treatment plan t be reflective f active treatment, as indicated by dcumentatin f changes in the type, amunt, frequency, and duratin f the treatment services rendered as the patient mves tward expected utcmes. Lack f prgress and its relatinship t active treatment and reasnable expectatin f imprvement shuld be nted (CMS L33624, 33975, 34183, 34570). It is expected as a matter f gd quality f care that careful discharge planning ccur t enable a successful transitin t utpatient care (CMS L33624, 34183, 34570). Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 5 f 6

6 REFERENCES Centers fr Medicare and Medicaid Services, Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, L33624-Natinal Gvernment Services, Inc., Cnnecticut, Illinis, Maine, Massachusetts, Minnesta, New Hampshire, New Yrk, Rhde Island, Vermnt, Wiscnsin. Octber 1, Retrieved frm Centers fr Medicare and Medicaid Services, Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, L33975-First Cast Service Optins, Inc., Flrida, Puert Ric, Virgin Islands. August 15, Retrieved frm Centers fr Medicare and Medicaid, Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, L Palmett GBA, Nrth C arlina, Suth Carlina, Virginia, West Virginia. Octber, 1, Retrieved frm Centers fr Medicare and Medicaid, Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, L34183-CGS Administratrs, Kentucky and Ohi. Octber 1, Retrieved frm HISTORY/REVISION INFORMATION Date March, 2014 Versin 1 May, 2015 Versin 2 March, 2017 Versin 3 June, 2017 Versin 4 January, 2018 Versin 5 Actin/Descriptin Psychiatric Inpatient Hspitalizatin Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 6 f 6