Psychiatry Coding & Reimbursement Alert

Good news: You will now have chances of reversal of denials due to delays.

If you need to admit a patient into an inpatient psychiatric facility (IPF), in order to allow payment through the IPF PPS (prospective payment system) under Medicare, your clinician will need to certify that the patient’s admission is medically necessary. Also, if the patient’s stay in the facility needs to be continued, your physician will need to recertify from time to time that the extension is necessary.

“The requirements for physician certification and recertification for inpatient psychiatric facility services under Medicare are similar to the requirements for certification and recertification for inpatient hospital services,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “However, there is an additional certification requirement that applies to all IPFs, including distinct part units of acute care hospitals, critical access hospitals, and psychiatric hospitals.”

Background: Whenever a patient is admitted as an inpatient into a psychiatric facility, you will need to have a certification that the patient’s admission is medically necessary, either at the time of admission or as soon as is reasonable and practicable thereafter. The certification must be provided by a physician, either the attending physician or another qualified physician who has knowledge of the case. “The Medicare rules are clear that this must be a physician rather than a non-physician health care professional,” Moore says.

Subsequently, to continue with the patient’s admission to the facility for active treatment, you will need to obtain a recertification as of the twelfth day of admission. You will need further such recertifications at certain intervals that are determined by the hospital’s utilization review committee on a case-by-case basis, and the period between such recertification should not exceed 30 days.

Understand the Methods of Obtaining Certification and Recertification

The certification is a “written statement.” There is no specific format in which you have to record it nor is there any specific form on which you have to include this.

You can either provide a written statement or get the attending physician to sign on a preprinted form. The statement of certification could also be entered in the patient’s chart notes or progress notes and signed by your physician. It does not matter which method you use to obtain the certification as long as you make sure that the requirements of certification of the patient’s admission are being met.

“The individual hospital determines the method by which certifications and recertifications are to be obtained and the format of the statement. The medical and administrative staffs of each hospital may adopt the form and procedure they find most convenient andappropriate, as long as the approach adopted by the hospital permits the Medicare administrative contractor (MAC) to determine that the certification and recertification requirements are, in fact, met,” Moore says.

Know the Requirements of Certification and Recertification

According to 42 CFR 424.14, reimbursement of your claims for an inpatient in a psychiatric facility will be denied if the requirements of certification and timely recertification are not met. When recording to the written or preprinted statement for certification, your physician should certify that the patient needs to be admitted as an inpatient to the psychiatric facility. Your clinician should note that the patient’s admission was medically necessary for getting active treatment to help improve the patient’s condition or for the purpose of diagnostic studies.

Along with providing information of medical necessity of admission of the patient, you will also need to include details about how long the patient might need to be admitted and information of any post-hospital care that is being planned.

When your physician is recertifying to continue the patient’s admission in the psychiatric facility, the recertification should also contain the written statement that the continued admission is medically necessary for continuing the active treatment as your clinician is expecting this treatment to help in the patient’s improvement. If the continued admission was necessary for diagnostic study, your clinician’s recertification should contain this information on record. Along with the written statement for recertification, you should also include hospital records that show the patient was provided with treatment or diagnostic services that were indicated when providing the initial certification of admission and that the treatment or the diagnostic study must be continued. The statement of recertification should inform that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel.

The period covered by the physician’s certification and recertification is referred to as a period during which the patient was receiving “active treatment.” If the patient remains in the hospital but the period of “active treatment” ends (e.g., because then treatment cannot reasonably be expected to improve the patient’s condition, or because intensive treatment services are not being furnished), Medicare payments can no longer be made. “Where the period of ‘active treatment’ ends, the physician is to indicate the ending date in making his recertification.  If ‘active treatment’ resumes after that, the physician should indicate, in making his recertification, the date on which it resumed,” Moore says.

Be Informed of New Changes to Certifications and Recertification

CMS has clarified in change request CR 9522 (that will be implemented on August 15, 2016) that it will henceforth cease denials of inpatient psychiatric facility providers who do not provide “the statement” that “the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel” for recertification of the patient’s continued need for treatment or diagnostic study when documentation is present that validates (without using any particular words) that the patient continues to need care. However, in lieu of not having a statement, your facility will still need to submit documentation in the form of medical records that will allow the MAC to get information that the patient needs continuation of the admission in your psychiatric facility. CR 9522 also informs that your MAC will use every possible method to verify that the patient needs to continue his inpatient stay.

“Apparently, some MACs were denying payments based on the fact that the recertification did not contain the specific language in question. CR 9522 makes it clear that MACs should focus on the content of the documentation, not the specific words that were used,” Moore says.

The change request 9522 also clarifies that you will need to continue providing certification and timely recertification for every patient that is admitted in your psychiatric facility. In case there is a delay in providing certification or recertification, your MAC might allow this delay if you provide a genuine reason for the delay. In case of a delayed submission of certification or recertification, your MAC will review the reasons you have provided for the delay and may allow a reversal if your reasons are found to be relevant.

The change request also includes information that delayed certifications and recertification can be included in a single statement that is signed by your physician. It also informs that the delayed certification cannot be produced after discharge of the patient.

Resources: For more information on certification and recertification of patient’s admission into an IPF under Medicare, see section 10.9 of chapter 4 of the Medicare General Information, Eligibility and Entitlement Manual, which is online at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c04.pdf.  For more information about change request 9522, check this MLM article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9522.pdf.