Inpatient Psychiatric Services for Under Age 21 Arkansas Medicaid Regulations and Documentation Presented by: Shelly Rhodes Shelly.Rhodes@beaconhealthoptions.com
Disclaimer Disclaimer: This presentation does not contain a legal description of all aspects of Medicaid clinical record documentation regulations. It is a practical guide for providers who participate in the Medicaid Program. The information provided is not intended to be allinclusive or otherwise limit the inquiry and consideration applicable to decisions regarding a beneficiary s rehabilitation needs. Guidelines and procedures in this presentation are based on requirements of States and Federal law. Thus the guidelines and procedures are subject to change if the requirements of the law or accrediting organization change. Where there is conflict between this edition of this presentation and a subsequent notification of a modification to a policy or procedure, the information in the subsequent notification shall prevail. 2
Admission 3
General Guidelines for Inpatient Services General Guidelines: Services must be medically necessary Beneficiary must be able to benefit from the treatment modality provided Services must meet the criteria of the Arkansas Medicaid Manual Certificate of Need (CON) for Services General Requirements (Section 215.100): In compliance with 42 CFR 441.152, the facility-based and independent CON teams must certify that: Ambulatory care resources available in the community do not meet the treatment needs of the recipient; Proper treatment of the recipient s psychiatric condition requires inpatient services under the direction of a physician and The services can be reasonably expected to prevent further regression or to improve the recipient s condition so that the services will no longer be needed. Inpatient Documentation 4
Admission Emergency Admission (Acute): Facility Based Certificate of Need (CON) Non-Emergency (elective admission-inpatient, RTC, PRTF): Primary Care Physician (PCP) referral (Inpatient onlyemergency admissions/acute not required) Independent CON Review (currently done by Beacon Health Options) Basic PowerPoint Template 5
Emergency Admissions (Acute Care) Emergency admissions (Section 215.500): Sudden onset of psychiatric conditions Acute symptoms requiring immediate medical attention to prevent serious dysfunction, death of the individual or harm to another by the individual Facility Based CON team (Section 215.210): Must be capable of and responsible for: Assessing immediate and long range therapeutic needs, development priorities and strengths and liabilities Assessing the potential resources of the family Make a recommendation regarding admission Develop treatment objectives Prescribe therapeutic modalities to achieve individual plan of care objectives and Preparing or reviewing information to be sent to the independent CON Team (Beacon Health Options) Basic PowerPoint Template 6
Emergency Admissions (Acute Care) For an emergency admission, the certification of need must be (Section 215.500): Requested by the facility-based team responsible for the individual plan of care and Requested at the time of admission and before the independent CON Team (Beacon Health Options) reviews for prior authorization. The admitting facility must notify the independent CON Team (Beacon Health Options) of all emergency admissions no later than two (2) working days after the admission. If more than two working days lapse, the independent CON Team will not issue a certification of need for the interval between admission and the date the CON is requested by the facility. Basic PowerPoint Template 7
Emergency Admissions (Acute Care) The independent CON team (Beacon Health Options) will conduct a review using the following information provided by the admitting facility (Section 215.500): Beneficiary s name, date of birth, county of residence and sex; Beneficiary s Medicaid ID number or Social Security Number; Facility name, provider identification number and date of admission; DSM diagnosis A description of the initial treatment plan relating to the admitting symptoms; Current symptoms requiring inpatient treatment; Medication history; Prior inpatient treatment; Prior outpatient or alternative treatment and Parent(s) or legal guardian(s) name, address and telephone number, if available. Basic PowerPoint Template 8
Non-Emergency Admissions(PRTF, RTC) Independent CON Team (Beacon Health Options) Admitting facility must initiate a pre-certification review by submitting the following (215.320): Beneficiary s name, date of birth, county of residence and sex; Beneficiary s current Medicaid ID number, if available, and Social Security number; Admitting facility s name, provider identification number and planned date of admission; DSM diagnosis Description of the initial treatment plan relating to the admitting symptoms; Current symptoms or chronic behavior requiring inpatient treatment; Medication history or cautions; Prior inpatient treatment; Prior outpatient treatment and Parent(s) or legal guardian(s) name, address and telephone number, if available. Basic PowerPoint Template 9
Admission Documentation Admission What is happening now to support admission? Precipitating events Severe, active psychiatric symptoms Attempts and response to lower levels of care/outpatient services Basic PowerPoint Template 10
Admission Evaluation 217.000 Admission Evaluation (42 CFR 456.170) After the CON determination by the independent CON team and no later than sixty (60) hours after admission and before the Medicaid Agency Review Team (MART) prior authorizes services, the facility-based team attending physician or staff physician must make a medical evaluation of the recipient s need for care in the facility, and the appropriate facility-based team professional personnel must make a psychiatric and social evaluation. Documentation to support that both evaluations were conducted within the sixty (60) hour time frame must be maintained in the recipient s record. Basic PowerPoint Template 11
Admission Evaluation (continued) Each medical evaluation must include: A. Diagnoses; B. Summary of present medical findings; C. Medical history; D. Mental and physical functional capacity; E. Prognoses; F. A recommendation by a physician concerning: 1. Admission to the facility or 2. Continued care in the facility for individuals who apply for Medicaid while in the inpatient psychiatric facility and no later than fourteen (14) days after admission. Basic PowerPoint Template 12
Admission Evaluation (continued) G. Symptoms, complaints and complications indicating the need for admission. An original written report of each admission evaluation (medical, psychiatric, social) must be prepared by the facility-based team and placed in the recipient s records along with the plan of care Basic PowerPoint Template 13
Plan of Care 14
Plan of Care 218.000 Individual Plan of Care (42 CFR 441.154) Inpatient psychiatric services must involve active treatment as specified in the written plan of care. Implementation of the individual plan of care must be supervised by professional staff. The original of each individual plan of care must be placed in the recipient s records. Basic PowerPoint Template 15
Plan of Care-Active Treatment Active Treatment is: Structured, scheduled services and activities Services which require the patient to participate Family involvement Discharge Planning Based on an integrated program of therapies/services designed to meet active treatment objectives Designed to improve the beneficiary s condition so that inpatient psychiatric services are no longer necessary Basic PowerPoint Template 16
Plan of Care Individual Plan of Care (Section 218.100): Written plan developed for each recipient to improve their condition to the extent that inpatient care is no longer necessary. The Plan of Care must be: Developed no later than fourteen (14) days after admission and before prior authorization of services; Designed to improve the recipient s condition to the extent that inpatient psychiatric services will no longer be necessary and to achieve the recipient s discharge from inpatient status at the earliest possible time; Basic PowerPoint Template 17
Plan of Care (Continued) Based on a diagnostic evaluation that includes examination of the medical, social, psychological, behavioral and developmental aspects of the recipient s situation and reflects the need for inpatient psychiatric services and Developed: 1. By the facility-based team and 2. In consultation with the recipient and his or her parent(s), legal guardian(s) or others in whose care he or she will be released after discharge. Basic PowerPoint Template 18
Plan of Care Plan of Care must include (Section 218.200): diagnoses, symptoms, complaints and complications indicating the need for admission to inpatient care description of the functional level of the recipient; plans for continuing care, including review and modification to the plan of care and discharge plans and, at an appropriate time, post-discharge plans, and also include the coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient s family, school and community upon discharge. Basic PowerPoint Template 19
Plan of Care Plan of Care must (Section 218.200): state treatment objectives state any orders for medications, special dietary needs, treatments, restorative and rehabilitative services or special procedures recommended for the health and safety of the recipient and contain an integrated program of therapies, social services activities and experiences designed to meet the treatment objectives. (Section 218.300) Be reviewed every 30 days to Determine if services being provided are or were required on an inpatient basis and Recommend changes in the plan as indicated by overall response to treatment Basic PowerPoint Template 20
Family Participation Family Participation in Treatment Required in treatment planning (per Section 218.100-developed in consultation with the recipient and legal guardian(s) or others in whose care he or she will be released after discharge) Document: all attempts at family/guardian contact all instances of contact any barriers ongoing discharge planning with guardians or other agencies Basic PowerPoint Template 21
Therapeutic Leave 22
Therapeutic Leave Section 222.110 Therapeutic Leave Days The Arkansas Medicaid Program covers a maximum of seven (7) consecutive days for therapeutic leave days. Therapeutic leave days must be clearly documented in the recipient s record. At a minimum, the recipient s record must reflect: The purpose of the therapeutic leave (therapeutic leave shall be listed in the plan of care along with the objectives, goals and frequency of this therapy); The destination or location (the place where the recipient will go for this therapy must be recorded as well as the date and time of departure and return and the person(s) responsible for the recipient during the leave period); Basic PowerPoint Template 23
Therapeutic Leave (continued) A therapeutic leave evaluation documentation that provides unquestionable support to the plan of care objectives and goals; Documentation of staff contact with the recipient and the person(s) responsible for the recipient for those therapeutic leaves in excess of seventy-two (72) consecutive hours and Progress notes that provide statements that track a recipient s actions and reactions, and must clearly reveal the recipient s achievements or regressions while on therapeutic leave. Basic PowerPoint Template 24
Documenting Medical Necessity 25
Documenting Medical Necessity Documentation: Does my documentation support medical necessity? Identify specific services provided; support each therapy, service, activity or session provided; Describe the relationship of the services to the treatment regimen described in the plan of care; Include updates of patient s progress; Must be legible and concise Basic PowerPoint Template 26
Medical Necessity Definition of Medical Necessity (Section IV-11) All Medicaid benefits are based upon medical necessity. A service medically necessary if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service. Basic PowerPoint Template 27
Medical Necessity (Continued) Definition of Medical Necessity (Section IV-11) For this purpose, a course of treatment may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program or by the Medicaid Program Quality Improvement Organization (QIO). Coverage may be denied if a service is not medically necessary in accordance with the preceding criteria or is generally regarded by the medical profession as experimental inappropriate or ineffective using unless objective clinical evidence demonstrates circumstances making the service necessary. Basic PowerPoint Template 28
Documentation 204.100 Documentation The provider must develop and maintain sufficient documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: The specific service provided The date and actual time the services were provided (Time frames may not overlap between services. All services must be outside the time frame of other services) Name and title of the person who provided the services The setting in which the services were provided The relationship of the services to the treatment regimen described in the plan of care Updates describing the patient s progress Basic PowerPoint Template 29
Documentation 204.100 Documentation (continued) Documentation must be legible and concise. The name and title of the person providing the Service must reflect the appropriate professional level. All documentation must be available to representatives of the Division of Medical Services at the time of an audit by the Field Audit Unit. All documentation must be available at the provider s place of business. No more than thirty (30) days will be allowed after the date on the recoupment notice in which additional documentation will be accepted. Additional documentation will no be accepted after the 30- day period. Basic PowerPoint Template 30
Documenting the Ability to Benefit Ability to Benefit from Treatment Is the individual cognitively capable of responding to and incorporating the treatment delivered? Intellectual Disability Developmental Disability Severe, active psychotic factors Neurological/physiological factors Over-medicated or intoxicated Milieu and social distractions Is the individual capable of applying what has been incorporated to exhibit a permanent or long-term, positive behavioral change? Basic PowerPoint Template 31
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