Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.
Inpatient Psychiatric Facility Services Certification and Recertification Requirements:
There is a difference in the content of the certification and recertification statements. The required physician's statement should certify that the inpatient psychiatric facility admission was medically necessary for either: (1) treatment which could reasonably be expected to improve the patient's condition, or (2) diagnostic study.
The physician's recertification should state each of the following:
1. that inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:
- treatment which could reasonably be expected to improve the patient's condition; or
- 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
3. 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.
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 after 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;
- a description of the 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 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
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 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;
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:
- within the first 3 program days after admission;
- by the physician, the multidisciplinary treatment team, and the patient; and
- should be based upon the problems identified in the physician’s diagnostic evaluation, psychosocial and nursing assessments.
2. The treatment plan should include:
- the specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished;
- the expected outcome for each problem addressed; and
- 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.
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 (e.g., 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.
It is expected as a matter of good quality of care that careful discharge planning occur to enable a successful transition to outpatient care.