01-305 Inpatient Psychiatric Facilities Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A billed on dates of service from January 16, 2019 through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Inpatient Psychiatric Facilities (IPFs) provide 24 hours of daily care in a structured, intensive, and secure setting for beneficiaries who cannot be safely or adequately managed at a lower level of care. The setting provides daily physician supervision, nursing, and treatment teams. Services provided to beneficiaries are evaluations, diagnostic services, and psychotherapeutic and medical interventions. Admitted Medicare beneficiaries must be under the care of a physician who is knowledgeable about the beneficiary and must certify and recertify the need for the inpatient psychiatric hospitalization.

The previous SMRC completed an IPF review in 2017 and had an overall claim error rate of 38%. The Office of Inspector General (OIG) audited claims on IPFs dated for fiscal years 2014-2015 and found 87% of claims with outlier payments did not meet Medicare requirements. A Comprehensive Error Rate Testing (CERT) report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service type with the highest improper payments.

Reason for Review

The SMRC is tasked with performing a claim review on a sample of Inpatient Psychiatric Facility claims from January 16, 2019 through December 31, 2019. The SMRC will conduct medical record reviews in accordance with the applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

POS/ Revenue Code/ TOB CPT/ HCPCS/ ICD-10/ DRG
TOB 111 DRG 885

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collection and submitting pertinent information to decrease provider burden.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Initial psychiatric, psychological evaluation, or mental status exam findings
  2. Any re-revaluations
  3. Medical and psychiatric history
  4. Physician orders including but not limited to medications, therapy, and any diagnostic tests
  5. Any diagnostic tests and results
  6. All progress notes or summaries
  7. Certifications and recertification
  8. Multi-disciplinary notes
  9. Treatment plan including any adjustments or revisions
  10. Treatment plan reviews
  11. Patient goals and progress towards goals
  12. Documentation for all therapeutic activities provided
  13. Medical Record Documentation to support the utilization of the DRG “885 Psychoses”
  14. Signatures and credentials of professionals providing services
  15. Copies of any patient notices given (for example, Advance Beneficiary Notice of Coverage (ABN))
  16. Discharge plan and summary
  17. Any abbreviation keys or acronym keys used
  18. All other documentation supporting the necessity of billed services
  19. Signature Log or attestation (if applicable) If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1812. Scope of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1814(a). Conditions of and Limitations on Payment for Services
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Providers must furnish information
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Payment to Providers of Services
  • Social Security Act (SSA) Title XVIII, Section 1832. Scope of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1834(w). Special Payment Rules for Particular Items and Services
  • Social Security Act (SSA) Title XVIII, Section 1835(a)(2)(F). Procedure for Payment of Claims of Providers of Services
  • Social Security Act (SSA) Title XVIII, Section 1836. Eligible Individuals
  • Social Security Act (SSA) Title XVIII, Section 1861. Definitions of Services, Institutions, etc.
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare As Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Social Security Act (SSA) Title XVIII, Section 1886. Payment to Hospitals for Inpatient Hospital Services
  • Social Security Act (SSA) Title XVIII, Section 1887. Payment of Provider-Based Physicians and Payment Under Certain Percentage Arrangements
  • Social Security Act (SSA) Title XVIII, Section 1893(b). Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 42, Section 164.501. Definitions
  • Code of Federal Regulations (CFR) Title 42, Section 409.62. Lifetime Maximum on Inpatient Psychiatric Care
  • Code of Federal Regulations (CFR) Title 42, Section 409.63. Reduction of Inpatient Psychiatric Benefit Days Available in the Initial Benefit Period
  • Code of Federal Regulations (CFR) Title 42, Section 410.3. Scope of Benefits
  • Code of Federal Regulations (CFR) Title 42, Section 412. Prospective Payment Systems for Inpatient Hospital Services
  • Code of Federal Regulations (CFR) Title 42, Section 424.14. Requirements for Inpatient Services of Inpatient Psychiatric Facilities
  • Code of Federal Regulations (CFR) Title 42, Section 424.5. Basic Conditions
  • Code of Federal Regulations (CFR) Title 42, Section 482. Conditions of Participation for Hospitals
  • Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual (IOM), Chapter 4, Sections 10.9 and 10.9.1. Inpatient Psychiatric Facility Services Certification and Recertification
  • Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 1. Inpatient Hospital Services Covered Under Part A
  • Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 10-90. Inpatient Psychiatric Hospital Services
  • Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 3, Section 30. Inpatient Days Counting Toward Benefit Maximums
  • Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 4, Sections 10-50. Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation
  • Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 5, Section 10.3. Availability of Reserve Days Where Psychiatric Limitations Are Involved
  • Internet Only Manual (IOM), Publication 100-03 National Coverage Determination (NCD) Manual, Chapter 1, Section 130, Mental Health
  • Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, section 190. Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.2. Time Frames for Submission
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 6, Section 6.5. Medical Review of Inpatient Hospital Claims for Part A Payment
  • National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 130.1. Inpatient Hospital Stays for the Treatment of Alcoholism
  • Local Coverage Determination (LCD) L34183 Psychiatric Inpatient Hospitalization. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L33975 Psychiatric Inpatient Hospitalization. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L33624 Psychiatric Inpatient Hospitalization. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L34570 Psychiatric Inpatient Hospitalization. Effective 10/01/2015-present
  • Local Policy Article (LCA) A55152 Psychiatric Inpatient Hospitalization revision to the Part A LCD. Effective 8/15/2016-present
  • Local Policy Article (LCA) A56303 Psychiatric Inpatient Hospitalization revision to the Part A LCD. Effective 1/24/2019-present
  • Local Policy Article (LCA) A57052 Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 9/26/2019-present
  • Local Policy Article (LCA) A57726 Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 10/3/2018-present
  • Local Policy Article (LCA) A56865 Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 11/14/2019-present
  • Local Policy Article (LCA) A56614 Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 6/20/2019-present

Last Updated Feb 16, 2022