Widespread Probe Review Results for Alabama Community Mental Health Centers

Part A Medical Review has recently completed the prepay probe review of Community Mental Health Centers (CMHCs), type of bill 76X.  The claims billing this service were randomly selected across the provider community that met the parameters of the edit. The review results are as follows:

Providers Reviewed:                      6
Claims Reviewed:                        90
Claims Approved:                        46
Claims Denied:                             44
Charges Reviewed:    $321,673.00
Charges Approved:    $156,902.50
Charges Denied:        $164,770.50
Error Rate:                               51%

* Error rate is based on the charges denied divided by the charges reviewed

The medical review decisions were based on the local coverage determination (LCD) for Partial Hospitalization Programs (L857).

Indications

Overview

Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in section 1861(ff) of the Social Security Act (the Act).  The treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient program.  It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation.  Programs providing primarily social, recreational, or diversionary activities are not considered partial hospitalization.

Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling.  According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.

Eligibility for Medicare coverage of a PHP comprise one of two groups:

  • Those patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment. Where partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP.
  • Those patients who, in the absence of partial hospitalization, would be at reasonable risk of requiring inpatient hospitalization

Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial.  Patients must also have the need for the active treatment provided by the program of services. It is the need for intensive, active treatment of his/her condition to maintain a functional level and to prevent relapse or hospitalization, which qualifies the patient to receive the services.

This program of services provides for the diagnosis and active, intensive treatment of the individual’s serious psychiatric condition and, in combination, are reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization.  A particular individual covered service (described above) as intervention, expected to maintain or improve the individual’s condition and prevent relapse, may also be included within the plan of care, but the overall intent of the partial program admission is to treat the serious presenting psychiatric symptoms.  Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent hospitalization.

Patients admitted to a PHP do not require 24 hour per day supervision as provided in an inpatient setting, and must have an adequate support system to sustain/maintain themselves outside the PHP.  Patients admitted to a PHP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5 of the most current edition of the International Classification of Diseases (ICD), which severely interferes with multiple areas of daily life.  The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from participating in an active treatment program. It is the need, as certified by the treating physician, for the intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patient’s presenting psychiatric condition.

Covered Services

Items and services that can be included as part of the structured, multimodal active treatment program, include:

  • Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);
  • Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;
  • Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;
  • Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
  • Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
  • Family counseling services for which the primary purpose is the treatment of the patient’s condition;
  • Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
  • Medically necessary diagnostic services related to mental health treatment.

Limitations

Noncovered Services-Benefit Category Denials

  • Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
  • Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
  • Patients who are otherwise psychiatrically stable or require medication management only.

Noncovered Services-Coverage Denials

  • Services to hospital inpatients;
  • Meals, self-administered medications, transportation; and
  • Vocational training.

Noncovered-Reasonable and Necessary Denials

  • Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or
  • Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.
  • CPT codes 90875 and 90876

The majority of denials were due to one of the following reasons:

  • Lack of timely submission of requested documentation (Denial Reason Code 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to The Medicare Program Integrity Manual, (CMS Pub. 100-08, Ch. 3, §3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond.  If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied. 

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

  • Providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR.  Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001.  Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
  • Print screen the ADR letter and attach the copy to the front of the requested medical documentation.
  • Send requested information to the address on the ADR letter
  • Do NOT send certified mail or overnight mail
  • Include ALL requested documentation outlined in the ADR
  • Submit the above information via regular mail within 30 days from the date of the request.  If the information is not received within 45 days from the date of the request, the claim will be automatically denied with denial reason code 56900.
  • Inadequate medical justification submitted (Denial Reason Code 54155):  This denial reason was due to the documentation submitted did not support medical necessity for the initiation of PHP services or the continued treatment in PHP level of care.
  • The patient did not meet the benefit category requirements for services at the partial hospital level of care. (Denial Reason Code 54361):  Claims were denied due to the patient not meeting the benefit category requirements for the services provided.  The patient was not recently discharged from an inpatient hospital treatment program and the PHP was in lieu of continued inpatient treatment or the patient would not be at reasonable risk of requiring inpatient hospitalization in the absence of partial hospitalization.

As a result of this prepay probe review, Part A Medical Review will continue with a prepay targeted review of all CMHC with the type of bill 76X.  Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review. 

Page last updated: Jan. 28, 2008

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