Local Coverage Article Billing and Coding

Billing and Coding: Psychiatric Inpatient Hospitalization

A56865

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A56865
Article Title
Billing and Coding: Psychiatric Inpatient Hospitalization
Article Type
Billing and Coding
Original Effective Date
11/14/2019
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2020 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Psychiatric Inpatient Hospitalization. 

National Coverage Provisions:

For services in an IPF (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 for the purpose of diagnosis; and
  • supervised and evaluated by a physician.

Such factors as diagnosis, length of hospitalization, and the degree of functional limitation, while useful as general indicators of the kind of care most likely being furnished in a given situation, are not controlling in deciding whether the care was active treatment. Refer to 42 CFR 482.61 on "Conditions of Participation for Hospitals" for a full description of what constitutes active treatment (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.2.1).

The services must be provided in accordance with an individualized program of treatment or diagnosis developed by a physician in conjunction with staff members of appropriate other disciplines on the basis of a thorough evaluation of the patient's -strengths and disabilities. The plan of treatment must be recorded in the patient's medical record in accordance with 42 CFR 412.27(c)(3) and the Conditions of Participation for Hospitals in 42 CFR 482.61.

The services provided must reasonably be expected to improve the patient's condition or must be for the purpose of diagnostic study. It is not necessary that a course of therapy have as its goal the restoration of the patient to a level which would permit discharge from the institution although the treatment must, at a minimum, be designed both to reduce or control the patient's psychotic or neurotic symptoms that necessitated hospitalization and improve the patient's level of functioning (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.3.2).

The types of services which meet the above requirements would include not only psychotherapy, drug therapy, and electroconvulsive therapy, but also such therapeutic activities as occupational therapy, recreational therapy, and milieu therapy, provided the therapeutic activities are expected to result in improvement (as defined above) in the patient's condition. If the only activities prescribed for the patient are primarily diversional in nature ( i.e., to provide some social or recreational outlet for the patient), it would not be regarded as treatment to improve the patient's condition. In many large hospitals these adjunctive services are present and part of the life experience of every patient. In a case where milieu therapy, (or one of the other adjunctive therapies) is involved, it is particularly important that this therapy be a planned program for the particular patient and not one where life in the hospital is designated as milieu therapy (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.3).

In accordance with the above definition of improvement, the administration of antidepressant or tranquilizing drugs that are expected to significantly alleviate a patient's psychotic or neurotic symptoms would be termed active treatment (assuming that the other elements of the definition are met). However, the administration of a drug or drugs does not necessarily constitute active treatment. 

Physician participation in the services is an essential ingredient of active treatment. The services of qualified individuals other than physicians, e.g., social workers, occupational therapists, group therapists, attendants, etc., must be prescribed and directed by a physician to meet the specific needs of the individual. In short, the physician must serve as a source of information and guidance for all members of the therapeutic team who work directly with the patient in various roles. It is the responsibility of the physician to periodically evaluate the therapeutic program and determine the extent to which treatment goals are being realized and whether changes in direction or emphasis are needed. Such evaluation should be made on the basis of periodic consultations and conferences with therapists, reviews of the patient's medical record, and regularly scheduled patient interviews, at least once a week (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.3). 

When the physician periodically evaluates the therapeutic program to determine the extent to which treatment goals are being realized and whether changes in direction or emphasis are needed (based on consultations and conferences with therapists, review of the patient's progress as recorded on the medical record and the physician's periodic conversations with the patient), active treatment would be indicated. A finding that a patient is not receiving active treatment will not in itself preclude payment for physicians' services under Medicare Part B. As long as the professional services rendered by the physician are reasonable and necessary for the care of the patient, such services would be reimbursable under the medical insurance program. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.3).

The period of time covered by the physician's certification is referred to a period of active treatment. This period should include all days on which inpatient psychiatric facility services were provided because of the individual's need for active treatment (not just the days on which specific therapeutic or diagnostic services are rendered). For example, a patient's program of treatment may necessitate the discontinuance of therapy for a period of time or it may include a period of observation, either in preparation for or as a follow-up to therapy, while only maintenance or protective services are furnished. If such periods were essential to the overall treatment plan, they would be regarded as part of the period of active treatment (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.2.1).

The fact that a patient is under the supervision of a physician does not necessarily mean the patient is getting active treatment. For example, medical supervision of a patient may be necessary to assure the early detection of significant changes in his/her condition; however, in the absence of a specific program of therapy designed to effect improvement, a finding that the patient is receiving active treatment would be precluded (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.2.1).

The program's definition of active treatment does not automatically exclude from coverage services rendered to patients who have conditions that ordinarily result in progressive physical and/or mental deterioration. Although patients with such diagnosis will most commonly be receiving custodial care, they may also receive services which meet the program's definition of active treatment (e.g., where a patient with Alzheimer's disease or Pick's disease received services designed to alleviate the effects of paralysis, epileptic seizures, or some other neurological symptom, or where a patient in the terminal stages of any disease received life- supportive care). A period of hospitalization during which services of this kind were furnished would be regarded as a period of active treatment. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.2.1).

 

Payment may be made for items and services furnished in or by a participating State or local government hospital, including a psychiatric or tuberculosis hospital, which serves the general community. A psychiatric hospital to which patients convicted of crimes are committed involuntarily is considered to be serving the general community if State law provides for voluntary commitment to the institution. However, payment may not be made for services furnished in or by State or local hospitals which serve only a special category of the population, but do not serve the general community, e.g., prison hospitals.

This policy does NOT address the following issues:

1. Life Time Limits and Spell of Illness Limits to psychiatric hospitalization services as defined by the CMS Publication 100-02, Medicare Benefit Policy Manual, Chapters 3 and 4. Nothing in this policy can be used to either expand or contract those limits; however, coverage may be denied for medical necessity reasons even though the beneficiary has not exhausted the life time limit or spell of illness limit for psychiatric hospitalization services.
2. Notice to Beneficiaries as described in CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 60 – 60.1.1.
3. Psychiatric Advance Directives as defined in 42 CFR Section 482.13(b)(3). All requirements related to Psychiatric Advance Directives must be met as part of the Hospital Conditions of Participation for Patients Rights.
4. Chemical or Physical Restraints, Seclusion, or Behavior Management within a psychiatric plan of care. These issues are addressed extensively in the Hospital Patient's Rights Legislation published in 64 FR 36070, July 2, 1999. All applicable requirements described in this publication must be met.
5. Certification of Facilities as psychiatric hospitals, psychiatric Inpatient Units within a Psychiatric Institution, or Psychiatric Inpatient Units within a General Hospital as defined in CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Sections 20.3, 20.4, 20.5, 20.6 and 20.7. All requirements described in the Medicare interpretive manuals apply.6. Items and Services Furnished, Paid for or Authorized by Governmental Entities as defined by CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 50.3.1.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentation Requirements:

Documentation that supports medical necessity and active treatment may take many forms. These documentation requirements are intended to help providers identify those documentation elements that will best support the medical necessity of the services they render. It is not expected that every item of these documentation requirements will appear in every record. Upon medical review, the IPF record will be reviewed as a whole, and services may be denied only if there is insufficient documentation to support the medical necessity of the claim.

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The reasons for admission must be clearly documented as stated by the patient or others significantly involved, or both.

Listing an ICD-10-CM code in the Mental Disorders category (F01- F99) does not assure coverage of the specific service. Upon medical review, coverage criteria specified in the related Local Coverage Determination shall be applied to the entire medical record to determine medical necessity.

Medicare contractors may automatically deny a claim without any manual review if a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) specifies the circumstances under which a service is denied and those circumstances exist, or the service is specifically excluded from Medicare coverage by statute.



Inpatient Psychiatric Facility Services Certification and Recertification Requirements:


The physician's recertification should state:

  1. That inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:

    1. Treatment which could reasonably be expected to improve the patient's condition;

    2. Diagnostic study;
  2. The hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services, and
  1. Effective July 1, 2006, physicians will also be required to include a statement recertifying 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 convenience, the period covered by the physician's certification and recertification is referred to 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 the treatment cannot reasonably be expected to improve the patient's condition, or because intensive treatment services are not being furnished), program payment can no longer be made even though the patient has not yet exhausted his/her benefits. Where the period of "active treatment" ends, the physician is to indicate the ending date in making his recertification. If "active treatment" thereafter resumes, the physician should indicate, in making his recertification, the date on which it resumed (CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 10.9)

Initial Psychiatric Evaluation:

The initial psychiatric evaluation with medical history and physical examination should be performed within 24 hours of admission, but in no case later than 60 hours of admission, in order to establish medical necessity for psychiatric inpatient hospitalization services. In order to support the medical necessity of admission, the documentation in the initial psychiatric evaluation should include, whenever available, the following items:

  • Patient’s chief complaint;
  • Description of acute illness or exacerbation of chronic illness requiring admission;
  • Current medical history, including medications and evidence of failure at or inability to benefit from a less intensive, outpatient program;
  • Past psychiatric and medical history;
  • History of substance abuse;
  • Family, vocational and social history;
  • Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self harm and harm to others, insight, judgment, capacity for activities of daily living (ADLs);
  • Physical examination;
  • Formulation of the patient’s status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the psychiatric inpatient hospitalization services; and
  • ICD-10-CM/DSM-5™ diagnoses, including all five axes of the multiaxial assessment as described in the DSM-5™.

A team approach may be used in developing the initial psychiatric evaluation and the plan of treatment (see “Plan of Treatment” section below), but the physician (MD/DO) must personally document the mental status examination, physical examination, diagnosis, and certification. It will not always be possible to obtain all the suggested information at the time of evaluation. In such cases, the limited information that is obtained and documented, must still be sufficient to support the need for an inpatient level of care.

Physician Orders:
Physician orders should include, but are not limited to, the following items:

  1. The types of psychiatric and medical therapy services and medications;
  2. Laboratory and other diagnostic testing;
  3. Allergies;
  4. Provisional diagnosis(es); and
  5. Types and duration of precautions (e.g., constant observation X 24 hours due to suicidal plans, restraints).

Plan of Treatment:
The Plan of Treatment is the tool used by the physician and multi-disciplinary treatment team to implement the physician-ordered services and move the patient toward the expected outcomes and goals. Although the Plan of Treatment is a requirement, the format and specific items to be included are up to the provider. Documentation of the parameters below is suggested to support the medical necessity for the inpatient services throughout the patient’s stay.

  1. This individualized, comprehensive, outcome-oriented plan of treatment should be developed:
    1. within the first three (3) program days after admission;
    2. by the physician, the multidisciplinary treatment team, and the patient; and should be
    3. based upon the problems identified in the physician’s diagnostic evaluation, psychosocial and nursing assessments.
  2. The treatment plan should include:
      1. the specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished;
      2. the expected outcome for each problem addressed; and
      3. contain outcomes that are measurable, functional, time-framed, and directly related to the cause of the patient’s admission.
  3. Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.

  4. The initial treatment plan and updated plans must be signed by the physician and those mental health professionals contributing to the treatment plan.

 

Progress Notes:

General:
A separate progress note should be written for each significant diagnostic and therapeutic service rendered and should be written by the team member rendering the service. Although each progress note may not contain every element, progress notes should include a description of the nature of the treatment service, the patient’s status (behavior, verbalizations, mental status) during the course of the service, the patient’s response to the therapeutic intervention and its relation to the long or short term goals in the treatment plan. Each progress note should be legible, dated and signed, and include the credentials of the rendering provider. It should be clear from the progress notes how the particular service relates to the overall plan of care.

Physician Progress Notes:
Physician progress notes should be recorded at each patient encounter and contain pertinent patient history, changes in signs and symptoms, with special attention to changes to the patient’s mental status, and results of any diagnostic testing. The notes should also include an appraisal of the patient’s status and progress, and the immediate plans for continued treatment or discharge. The course of the patient’s inpatient diagnostic evaluation and treatment should be able to be inferred from reading the physician progress notes.

Individual and Group Psychotherapy and Patient Education and Training Progress Notes:
Individual and group psychotherapy and patient education and training progress notes should describe the service being rendered, (i.e., name of group, group type, brief description of the content of the individual session or group), the patient’s communications, and response or lack of response to the intervention. Each progress note should reflect the particular characteristics of the therapeutic/educational encounter to distinguish it from other similar interventions.

Discharge Plan:
It is expected as a matter of good quality of care that careful discharge planning occur to enable a successful transition to outpatient care.

 

 

Coding Information

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

CPT coding does not apply.

Group 1 Codes

N/A

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The ICD-10-CM codes listed below represent conditions that often support medical necessity for inpatient psychiatric hospitalization. The list is not all inclusive. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the related determination. The codes selected are generally those codes that appear in the ICD-10-CM and that are also defined in the Diagnostic and Statistical Manual, fifth edition (DSM-5™).

Group 1 Codes
CodeDescription
F01.51 Vascular dementia with behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F06.0 Psychotic disorder with hallucinations due to known physiological condition
F06.1 Catatonic disorder due to known physiological condition
F06.2 Psychotic disorder with delusions due to known physiological condition
F06.31 Mood disorder due to known physiological condition with depressive features
F06.32 Mood disorder due to known physiological condition with major depressive-like episode
F06.33 Mood disorder due to known physiological condition with manic features
F06.34 Mood disorder due to known physiological condition with mixed features
F06.4 Anxiety disorder due to known physiological condition
F06.8 Other specified mental disorders due to known physiological condition
F10.121 Alcohol abuse with intoxication delirium
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.20 Alcohol dependence, uncomplicated
F10.221 Alcohol dependence with intoxication delirium
F10.230 Alcohol dependence with withdrawal, uncomplicated
F10.231 Alcohol dependence with withdrawal delirium
F10.232 Alcohol dependence with withdrawal with perceptual disturbance
F10.24 Alcohol dependence with alcohol-induced mood disorder
F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions
F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations
F10.280 Alcohol dependence with alcohol-induced anxiety disorder
F10.281 Alcohol dependence with alcohol-induced sexual dysfunction
F10.288 Alcohol dependence with other alcohol-induced disorder
F11.121 Opioid abuse with intoxication delirium
F11.13 Opioid abuse with withdrawal
F11.14 Opioid abuse with opioid-induced mood disorder
F11.150 Opioid abuse with opioid-induced psychotic disorder with delusions
F11.151 Opioid abuse with opioid-induced psychotic disorder with hallucinations
F11.181 Opioid abuse with opioid-induced sexual dysfunction
F11.188 Opioid abuse with other opioid-induced disorder
F11.20 Opioid dependence, uncomplicated
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F12.121 Cannabis abuse with intoxication delirium
F12.122 Cannabis abuse with intoxication with perceptual disturbance
F12.13 Cannabis abuse with withdrawal
F12.150 Cannabis abuse with psychotic disorder with delusions
F12.151 Cannabis abuse with psychotic disorder with hallucinations
F12.180 Cannabis abuse with cannabis-induced anxiety disorder
F12.188 Cannabis abuse with other cannabis-induced disorder
F12.221 Cannabis dependence with intoxication delirium
F12.222 Cannabis dependence with intoxication with perceptual disturbance
F12.250 Cannabis dependence with psychotic disorder with delusions
F12.251 Cannabis dependence with psychotic disorder with hallucinations
F12.280 Cannabis dependence with cannabis-induced anxiety disorder
F12.288 Cannabis dependence with other cannabis-induced disorder
F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium
F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated
F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium
F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance
F13.139 Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified
F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder
F13.150 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.181 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder
F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium
F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
F13.231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium
F13.232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance
F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder
F13.250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.26 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder
F14.121 Cocaine abuse with intoxication with delirium
F14.122 Cocaine abuse with intoxication with perceptual disturbance
F14.13 Cocaine abuse, unspecified with withdrawal
F14.14 Cocaine abuse with cocaine-induced mood disorder
F14.150 Cocaine abuse with cocaine-induced psychotic disorder with delusions
F14.151 Cocaine abuse with cocaine-induced psychotic disorder with hallucinations
F14.180 Cocaine abuse with cocaine-induced anxiety disorder
F14.181 Cocaine abuse with cocaine-induced sexual dysfunction
F14.188 Cocaine abuse with other cocaine-induced disorder
F14.20 Cocaine dependence, uncomplicated
F14.220 Cocaine dependence with intoxication, uncomplicated
F14.221 Cocaine dependence with intoxication delirium
F14.222 Cocaine dependence with intoxication with perceptual disturbance
F14.23 Cocaine dependence with withdrawal
F14.24 Cocaine dependence with cocaine-induced mood disorder
F14.250 Cocaine dependence with cocaine-induced psychotic disorder with delusions
F14.251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations
F14.280 Cocaine dependence with cocaine-induced anxiety disorder
F14.281 Cocaine dependence with cocaine-induced sexual dysfunction
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.288 Cocaine dependence with other cocaine-induced disorder
F14.93 Cocaine use, unspecified with withdrawal
F15.121 Other stimulant abuse with intoxication delirium
F15.122 Other stimulant abuse with intoxication with perceptual disturbance
F15.13 Other stimulant abuse with withdrawal
F15.14 Other stimulant abuse with stimulant-induced mood disorder
F15.150 Other stimulant abuse with stimulant-induced psychotic disorder with delusions
F15.151 Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations
F15.180 Other stimulant abuse with stimulant-induced anxiety disorder
F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction
F15.188 Other stimulant abuse with other stimulant-induced disorder
F15.20 Other stimulant dependence, uncomplicated
F15.220 Other stimulant dependence with intoxication, uncomplicated
F15.221 Other stimulant dependence with intoxication delirium
F15.222 Other stimulant dependence with intoxication with perceptual disturbance
F15.23 Other stimulant dependence with withdrawal
F15.24 Other stimulant dependence with stimulant-induced mood disorder
F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions
F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations
F15.280 Other stimulant dependence with stimulant-induced anxiety disorder
F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.288 Other stimulant dependence with other stimulant-induced disorder
F16.121 Hallucinogen abuse with intoxication with delirium
F16.122 Hallucinogen abuse with intoxication with perceptual disturbance
F16.14 Hallucinogen abuse with hallucinogen-induced mood disorder
F16.150 Hallucinogen abuse with hallucinogen-induced psychotic disorder with delusions
F16.151 Hallucinogen abuse with hallucinogen-induced psychotic disorder with hallucinations
F16.180 Hallucinogen abuse with hallucinogen-induced anxiety disorder
F16.183 Hallucinogen abuse with hallucinogen persisting perception disorder (flashbacks)
F16.188 Hallucinogen abuse with other hallucinogen-induced disorder
F16.221 Hallucinogen dependence with intoxication with delirium
F16.24 Hallucinogen dependence with hallucinogen-induced mood disorder
F16.250 Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions
F16.251 Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations
F16.280 Hallucinogen dependence with hallucinogen-induced anxiety disorder
F16.283 Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks)
F16.288 Hallucinogen dependence with other hallucinogen-induced disorder
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
F17.228 Nicotine dependence, chewing tobacco, with other nicotine-induced disorders
F17.298 Nicotine dependence, other tobacco product, with other nicotine-induced disorders
F18.121 Inhalant abuse with intoxication delirium
F18.14 Inhalant abuse with inhalant-induced mood disorder
F18.150 Inhalant abuse with inhalant-induced psychotic disorder with delusions
F18.151 Inhalant abuse with inhalant-induced psychotic disorder with hallucinations
F18.180 Inhalant abuse with inhalant-induced anxiety disorder
F18.188 Inhalant abuse with other inhalant-induced disorder
F18.20 Inhalant dependence, uncomplicated
F18.220 Inhalant dependence with intoxication, uncomplicated
F18.221 Inhalant dependence with intoxication delirium
F18.24 Inhalant dependence with inhalant-induced mood disorder
F18.250 Inhalant dependence with inhalant-induced psychotic disorder with delusions
F18.251 Inhalant dependence with inhalant-induced psychotic disorder with hallucinations
F18.27 Inhalant dependence with inhalant-induced dementia
F18.280 Inhalant dependence with inhalant-induced anxiety disorder
F18.288 Inhalant dependence with other inhalant-induced disorder
F19.121 Other psychoactive substance abuse with intoxication delirium
F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances
F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated
F19.131 Other psychoactive substance abuse with withdrawal delirium
F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance
F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder
F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions
F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations
F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.20 Other psychoactive substance dependence, uncomplicated
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.221 Other psychoactive substance dependence with intoxication delirium
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.24 Other psychoactive substance dependence with psychoactive substance-induced mood disorder
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.26 Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorder
F19.27 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.81 Schizophreniform disorder
F22 Delusional disorders
F23 Brief psychotic disorder
F24 Shared psychotic disorder
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
F25.8 Other schizoaffective disorders
F28 Other psychotic disorder not due to a substance or known physiological condition
F30.11 Manic episode without psychotic symptoms, mild
F30.12 Manic episode without psychotic symptoms, moderate
F30.13 Manic episode, severe, without psychotic symptoms
F30.2 Manic episode, severe with psychotic symptoms
F30.3 Manic episode in partial remission
F31.11 Bipolar disorder, current episode manic without psychotic features, mild
F31.12 Bipolar disorder, current episode manic without psychotic features, moderate
F31.13 Bipolar disorder, current episode manic without psychotic features, severe
F31.2 Bipolar disorder, current episode manic severe with psychotic features
F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate
F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features
F31.61 Bipolar disorder, current episode mixed, mild
F31.62 Bipolar disorder, current episode mixed, moderate
F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features
F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features
F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72 Bipolar disorder, in full remission, most recent episode hypomanic
F31.73 Bipolar disorder, in partial remission, most recent episode manic
F31.75 Bipolar disorder, in partial remission, most recent episode depressed
F31.77 Bipolar disorder, in partial remission, most recent episode mixed
F31.81 Bipolar II disorder
F32.0 Major depressive disorder, single episode, mild
F32.1 Major depressive disorder, single episode, moderate
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.4 Major depressive disorder, single episode, in partial remission
F32.A Depression, unspecified
F33.0 Major depressive disorder, recurrent, mild
F33.1 Major depressive disorder, recurrent, moderate
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.41 Major depressive disorder, recurrent, in partial remission
F40.01 Agoraphobia with panic disorder
F41.0 Panic disorder [episodic paroxysmal anxiety]
F43.0 Acute stress reaction
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F43.21 Adjustment disorder with depressed mood
F43.22 Adjustment disorder with anxiety
F43.23 Adjustment disorder with mixed anxiety and depressed mood
F43.24 Adjustment disorder with disturbance of conduct
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
F50.01 Anorexia nervosa, restricting type
F50.02 Anorexia nervosa, binge eating/purging type
F50.2 Bulimia nervosa
F50.82 Avoidant/restrictive food intake disorder
F51.8 Other sleep disorders not due to a substance or known physiological condition
F53.0 Postpartum depression
F53.1 Puerperal psychosis
F60.3 Borderline personality disorder
F63.81 Intermittent explosive disorder
F84.0 Autistic disorder
F84.3 Other childhood disintegrative disorder
F84.5 Asperger's syndrome
F84.8 Other pervasive developmental disorders
F93.0 Separation anxiety disorder of childhood
F98.3 Pica of infancy and childhood
R40.0 Somnolence
R40.1 Stupor
R45.850 Homicidal ideations
R45.851 Suicidal ideations
R45.88 Nonsuicidal self-harm
T14.91XA Suicide attempt, initial encounter
T14.91XD Suicide attempt, subsequent encounter
T14.91XS Suicide attempt, sequela

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

The following diagnoses (as a primary diagnosis and without a covered psychiatric diagnosis also on the claim) indicate a level of mental disorder for which inpatient treatment is not required. There may be rare exceptions to exclusion from coverage for the following diagnoses. Documentation in the medical record must provide clear rationale for the exception to exclusion.

Group 1 Codes
CodeDescription
F01.50 Vascular dementia without behavioral disturbance
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.21 Alcohol dependence, in remission
F10.220 Alcohol dependence with intoxication, uncomplicated
F11.10 Opioid abuse, uncomplicated
F11.120 Opioid abuse with intoxication, uncomplicated
F11.21 Opioid dependence, in remission
F12.10 Cannabis abuse, uncomplicated
F12.21 Cannabis dependence, in remission
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
F13.21 Sedative, hypnotic or anxiolytic dependence, in remission
F14.10 Cocaine abuse, uncomplicated
F14.120 Cocaine abuse with intoxication, uncomplicated
F14.21 Cocaine dependence, in remission
F15.10 Other stimulant abuse, uncomplicated
F15.120 Other stimulant abuse with intoxication, uncomplicated
F15.21 Other stimulant dependence, in remission
F16.10 Hallucinogen abuse, uncomplicated
F16.120 Hallucinogen abuse with intoxication, uncomplicated
F16.21 Hallucinogen dependence, in remission
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
F18.10 Inhalant abuse, uncomplicated
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.21 Inhalant dependence, in remission
F19.10 Other psychoactive substance abuse, uncomplicated
F19.120 Other psychoactive substance abuse with intoxication, uncomplicated
F19.21 Other psychoactive substance dependence, in remission
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia
F30.4 Manic episode in full remission
F31.74 Bipolar disorder, in full remission, most recent episode manic
F31.76 Bipolar disorder, in full remission, most recent episode depressed
F31.78 Bipolar disorder, in full remission, most recent episode mixed
F32.5 Major depressive disorder, single episode, in full remission
F33.42 Major depressive disorder, recurrent, in full remission
F42.2 - F42.9 Mixed obsessional thoughts and acts - Obsessive-compulsive disorder, unspecified
F45.41 Pain disorder exclusively related to psychological factors
F45.8 Other somatoform disorders
F51.01 Primary insomnia
F51.02 Adjustment insomnia
F51.03 Paradoxical insomnia
F51.09 Other insomnia not due to a substance or known physiological condition
F51.11 Primary hypersomnia
F51.12 Insufficient sleep syndrome
F51.19 Other hypersomnia not due to a substance or known physiological condition
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]
F51.5 Nightmare disorder
F51.8 Other sleep disorders not due to a substance or known physiological condition
F52.0 Hypoactive sexual desire disorder
F52.1 Sexual aversion disorder
F52.21 Male erectile disorder
F52.22 Female sexual arousal disorder
F52.31 Female orgasmic disorder
F52.32 Male orgasmic disorder
F52.4 Premature ejaculation
F52.6 Dyspareunia not due to a substance or known physiological condition
F52.8 Other sexual dysfunction not due to a substance or known physiological condition
F55.0 Abuse of antacids
F55.1 Abuse of herbal or folk remedies
F55.2 Abuse of laxatives
F55.3 Abuse of steroids or hormones
F55.4 Abuse of vitamins
F55.8 Abuse of other non-psychoactive substances
F63.3 Trichotillomania
F64.1 Dual role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F65.0 Fetishism
F65.1 Transvestic fetishism
F65.2 Exhibitionism
F65.3 Voyeurism
F65.4 Pedophilia
F65.51 Sexual masochism
F65.52 Sexual sadism
F65.81 Frotteurism
F65.89 Other paraphilias
F66 Other sexual disorders
F70 Mild intellectual disabilities
F71 Moderate intellectual disabilities
F72 Severe intellectual disabilities
F73 Profound intellectual disabilities
F78.A1 SYNGAP1-related intellectual disability
F78.A9 Other genetic related intellectual disability
F80.0 Phonological disorder
F80.1 Expressive language disorder
F80.2 Mixed receptive-expressive language disorder
F80.4 Speech and language development delay due to hearing loss
F80.81 Childhood onset fluency disorder
F80.89 Other developmental disorders of speech and language
F81.0 Specific reading disorder
F81.2 Mathematics disorder
F81.81 Disorder of written expression
F81.89 Other developmental disorders of scholastic skills
F82 Specific developmental disorder of motor function
F88 Other disorders of psychological development
F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2 Attention-deficit hyperactivity disorder, combined type
F90.8 Attention-deficit hyperactivity disorder, other type
F93.8 Other childhood emotional disorders
F98.0 Enuresis not due to a substance or known physiological condition
F98.1 Encopresis not due to a substance or known physiological condition
F98.5 Adult onset fluency disorder
H93.25 Central auditory processing disorder
R45.1 Restlessness and agitation
R45.81 Low self-esteem
R45.82 Worries
R48.0 Dyslexia and alexia
Z87.890 Personal history of sex reassignment

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R4

Based on the annual ICD-10 updates F78 was deleted from ICD-10-CM Codes that DO NOT Support Medical Necessity and replaced with F78.A1 and F78.A9. F32.A and R45.88 were added to ICD-10-CM Codes that Support Medical Necessity.

10/01/2020 R3

The article was revised to add T14.91XS, which was inadvertently omitted from ICD-10 Codes that Support Medical Necessity, Group 1 in a previous version.

10/01/2020 R2

Based on the annual ICD-10 updates for 2021, the following codes were added to ICD-10 Codes that Support Medical Necessity, Group 1: F11.13, F12.13, F13.130, F13.131, F13.132, F13.139, F14.13, F14.93, F15.13, F19.130, F19.131 and F19.132.

06/01/2020 R1

Reference to DSM-IV-TR™ was deleted and replaced with DSM-5™.

Associated Documents

Related Local Coverage Documents
LCDs
L33624 - Psychiatric Inpatient Hospitalization
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
09/24/2021 10/01/2021 - N/A Currently in Effect You are here
10/09/2020 10/01/2020 - 09/30/2021 Superseded View
09/25/2020 10/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A