Description
IInpatient hospital services furnished to a patient of an inpatient psychiatric facility will be reviewed to determine that services were medically reasonable and necessary. Services determined to be not medically reasonable and necessary will result in an overpayment.
Affected Code(s)
11X Hospital Inpatient (Part A) and Inpatient Psychiatric Facility excluding type of bills 118, 11P and 110, 117, 11G, 11H, 11I, 11Q
Applicable Policy References
1. Title XVIII of the Social Security Act (SSA), Section 1814(a)(2)(A) and (4)- Conditions of and Limitations on Payment for Services
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1815(a)- Payment to Providers of Services
3. Title XVIII of the Social Security Act (SSA), Section 1833(e)- Payment of Benefits
4. Title XVIII of the Social Security Act (SSA), Section 1835(a)- Procedure for Payment of Claims of Providers of Services
5. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
8. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
9. 42 CFR §405.986 - Good Cause for Reopening
10. 42 CFR 409.62- Lifetime Maximum on Inpatient Psychiatric Care
11. 42 CFR 412.27(c)- Excluded Psychiatric Units: Additional Requirements
12. 42 CFR 412.404- Conditions for Payment under the Prospective Payment System for Inpatient Hospital Services of Psychiatric Facilities
13. 42 CFR 424.14- Requirements for Inpatient Services of Inpatient Psychiatric Facilities
14. 42 CFR §424.5(a)(6)- Sufficient Information
15. 42 CFR 482.61- Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
16. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10.9- Inpatient Psychiatric Facility Services Certification and Recertification
17. Medicare Benefit Policy Manual, Chapter 2- Inpatient Psychiatric Hospital Services, section 20- Admission Requirements; section 30- Medical Records Requirements; section 30.1- Development of Assessment/Diagnostic Data; section 30.2- Psychiatric Evaluation; section 30.2.1- Certification and Recertification Requirements; section 30.2.1.1- Certification; section 30.2.1.2- Recertification; section 30.2.1.3- Delayed/Lapsed Certification and Recertification; section 30.3- Treatment Plan; section 30.3.1- Individualized Treatment or Diagnostic Plan; section 30.3.2- Services Expected to Improve the Condition or for Purpose of Diagnosis; section 30.4 - Recording Progress; section 30.5- Discharge Planning and Discharge Summary
18. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, section 190- Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
20. American Psychiatric Association Diagnostic and Statistical Manual, Text Revision, Fifth Edition
21. ICD-10-CM codebook, Chapter 5- Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
22. Inpatient Psychiatric Facility PPS FY Addendum A Final PPS Payment Updates https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientPsychFacilPPS/tools
23. MS-DRG Payment Book current year