Summary Of Evidence

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Analysis of Evidence

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Abstract:

Inpatient psychiatric hospitalization provides 24 hours of daily care in a structured, intensive, and secure setting for patients who cannot be safely and/or adequately managed at a lower level of care. This setting provides daily physician (MD/DO) supervision, 24-hour nursing/treatment team evaluation and observation, diagnostic services, and psychotherapeutic and medical interventions.

Inpatient psychiatric care may be delivered in a psychiatric hospital, a psychiatric hospital acute care unit within a psychiatric institution, or a psychiatric inpatient unit within a general hospital.

Indications:

Medicare patients admitted to inpatient psychiatric hospitalization must be under the care of a physician who is knowledgeable about the patient. The physician must certify/recertify (see Associated Information- Documentation Requirements section) the need for inpatient psychiatric hospitalization. The patient must require active treatment of his/her psychiatric disorder. The patient or legal guardian must provide written informed consent for inpatient psychiatric hospitalization in accordance with state law. If the patient is subject to involuntary or court-ordered commitment, the services must still meet the requirements for medical necessity in order to be covered by Medicare.

Admission Criteria (Intensity of Service):

The patient must require intensive, comprehensive, multimodal treatment including 24 hours per day of medical supervision and coordination because of a mental disorder. The need for 24 hours of supervision may be due to the need for patient safety, psychiatric diagnostic evaluation, potential severe side effects of psychotropic medication associated with medical or psychiatric comorbidities, or evaluation of behaviors consistent with an acute psychiatric disorder for which a medical cause has not been ruled out.

The acute psychiatric condition being evaluated or treated by inpatient psychiatric hospitalization must require active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting, including psychiatric partial hospitalization. There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting. Claims for care delivered at an inappropriate level of intensity will be denied.

The following parameters are intended to describe the severity of illness and intensity of service that characterize a patient appropriate for inpatient psychiatric hospitalization. These criteria do not represent an all-inclusive list and are intended as guidelines.

Admission Criteria (Severity of Illness):

Examples of inpatient admission criteria include (but are not limited to):

1. Threat to self requiring 24-hour professional observation:

• suicidal ideation or gesture within 72 hours prior to admission;
• self mutilation (actual or threatened) within 72 hours prior to admission;
• chronic and continuing self destructive behavior (e.g., bulimic behaviors, substance abuse) that poses a significant and/or immediate threat to life, limb, or bodily function.

2. Threat to others requiring 24-hour professional observation:

• assaultive behavior threatening others within 72 hours prior to admission
• a significant verbal threat to the safety of others within 72 hours prior to admission.

3. Command hallucinations directing harm to self or others where there is the risk of the patient taking action on them.

4. Acute disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities of daily living (ADLs) so that the patient cannot function at a less intensive level of care during evaluation and treatment.

5. Cognitive impairment (disorientation or memory loss) due to an acute psychiatric disorder that endangers the welfare of the patient or others.

6. For patients with a dementing disorder for evaluation or treatment of a psychiatric comorbidity (e.g., risk of suicide, violence, severe depression) warranting inpatient admission.

7. A mental disorder causing major disability in social, interpersonal, occupational, and/or educational functioning that is leading to dangerous or life-threatening functioning, and that can only be addressed in an acute inpatient setting.

8. A mental disorder that causes an inability to maintain adequate nutrition or self-care, and family/community support cannot provide reliable, essential care, so that the patient cannot function at a less intensive level of care during evaluation and treatment.

9. Failure of outpatient psychiatric treatment so that the beneficiary requires 24-hour professional observation and care. Reasons for the failure of outpatient treatment could include:

• increasing severity of psychiatric symptoms;
• noncompliance with medication regimen due to the severity of psychiatric symptoms;
• inadequate clinical response to psychotropic medications;
• the inability of the patient to participate in an outpatient psychiatric treatment program due to the severity of psychiatric symptoms.

NOTE: For all symptom sets or diagnoses: the severity and acuity of symptoms and the likelihood of response to treatment, combined with the requirement for an intensive, 24-hour level of care are the significant factors in determining the necessity of inpatient psychiatric treatment.

Active Treatment:

For services in an inpatient psychiatric facility to be designated as active treatment, they must be:

• provided under an individualized treatment or diagnostic plan;
• reasonably expected to improve the patient’s condition or are for the purpose of diagnosis; and
• supervised and evaluated by a physician.

Discharge Criteria (Intensity of Service):

Patients in inpatient psychiatric care may be discharged by stepping down to a less intensive level of outpatient care. Stepping down to a less intensive level of service than inpatient hospitalization would be considered when patients no longer require 24-hour care for safety, diagnostic evaluation, or active treatment as described above. These patients would become outpatients, receiving either psychiatric partial hospitalization or individual outpatient mental health services.

Discharge Criteria (Severity of Illness):

Patients whose clinical condition improves or stabilizes, who no longer pose an impending threat to self or others, and who do not still require 24-hour care available in an inpatient psychiatric unit should be stepped down to outpatient care. Patients who are persistently unwilling or unable to participate in active treatment of their psychiatric condition would also be appropriate for discharge.

Limitations:

1. Failure to provide documentation to support the necessity of test(s) or treatment(s) may result in denial of claims or services. This includes medical records:

• that do not support that the services are reasonable and necessary;
• in which the documentation is illegible; or
• where medical necessity for inpatient psychiatric services is not appropriately certified by the physician.

2. The following services do not represent reasonable and medically necessary inpatient psychiatric services and coverage is excluded:

• services which are primarily social, recreational or diversion activities, or custodial or respite care;
• services attempting to maintain psychiatric wellness for the chronically mentally ill;
• treatment of chronic conditions without acute exacerbation;
• vocational training;
• when supporting medical records fail to document the required level of physician supervision and treatment planning process;
• electrosleep therapy;
• electrical aversion therapy for treatment of alcoholism;
• hemodialysis for the treatment of schizophrenia;
• transcendental meditation;
• multiple electroconvulsive therapy (MECT).

3. It is not reasonable and medically necessary to provide inpatient psychiatric hospital services to the following types of patients:

• patients who require primarily social, custodial, recreational, or respite care;
• patients whose clinical acuity requires less than 24 hours of supervised care per day;
• patients who have met the criteria for discharge from inpatient hospitalization;
• patients whose symptoms are the result of a medical condition that requires a medical/surgical setting for appropriate treatment;
• patients whose primary problem is a physical health problem without a concurrent major psychiatric episode;
• patients with alcohol or substance abuse problems who do not have a combined need for active treatment and psychiatric care that can only be provided in the inpatient hospital setting;
• patients for whom admission to a psychiatric hospital is being used as an alternative to incarceration.

4. Coverage criteria specified in this Local Coverage Determination (LCD) shall be applied to the entire medical record to determine medical necessity.