01-305 Inpatient Psychiatric Facility Findings of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted post-payment review of claims for Medicare Part A Inpatient Psychiatric Facility services billed on dates of service from January 16, 2019, through December 31, 2019. Below are the review results:
|Project ID||Project Title||Error Rate|
|01-305||Inpatient Psychiatric Facilities||26%|
Inpatient Psychiatric Facilities (IPFs) provide 24 hours of daily care in a structured, intensive, and secure setting for beneficiaries who cannot be safely or adequately managed at a lower level of care. In 2017, the SMRC completed an IPF review and found an overall claim error rate of 38%. The Office of Inspector General (OIG) audited claims on IPFs dated for fiscal years 2014-2015 and found 87% of claims with outlier payments did not meet Medicare requirements. A Comprehensive Error Rate Testing (CERT) report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service type with the highest improper payments.
Reason for Review
The SMRC was tasked with performing a claim review on a sample of Inpatient Psychiatric Facility claims from January 16, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with the applicable statutory, regulatory, and sub-regulatory guidance.
Common Reasons for Denial
- Insufficient Documentation
- The documentation submitted lacked evidence that category requirements were met. Incomplete/Insufficient information. Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 22.214.171.124 C, Social Security Act 1833(e), 42 CFR 424.5(a)(6).
- Non-Response to the Documentation Request
- The medical records requested were not submitted. Provider did not submit additional records requested. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 126.96.36.199 B/C, 42 CFR 424.5(a)(6), Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). The documentation was not submitted or not submitted timely.
- The documentation submitted did not include the required certifications or recertifications for the inpatient psychiatric stay. Refer to Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.1, Pub 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 10.9. The certification and/or recertification were not submitted or not submitted timely.
Social Security Act (SSA) Title XVIII
- §1812. Scope of Benefits.
- §1814(a). Conditions of and Limitations on Payment for Services.
- §1815(a). Payment to Providers of Services.
- §1832. Scope of Benefits.
- §1833(e). Payment of Benefits.
- §1834(w). Special Payment Rules for Particular Items and Services.
- §1835(a)(2)(F). Procedure for Payment of Claims of Providers of Services.
- §1836. Eligible Individuals.
- §1861. Definitions of Services, Institutions, etc.
- §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
- §1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
- §1886. Payment to Hospitals for Inpatient Hospital Services.
- §1887. Payment of Provider-Based Physicians and Payment Under Certain Percentage Arrangements.
- §1893(b). Medicare Integrity Program.
Code of Federal Regulations (CFR) Title 42
- 409.62. Lifetime Maximum on Inpatient Psychiatric Care.
- 409.63. Reduction of Inpatient Psychiatric Benefit Days Available in the Initial Benefit Period.
- 410.3. Scope of Benefits.
- 412. Prospective Payment Systems for Inpatient Hospital Services.
- 424.14. Requirements for Inpatient Services of Inpatient Psychiatric Facilities.
- 424.5. Basic Conditions.
- 482. Conditions of Participation for Hospitals.
Code of Federal Regulations (CFR) Title 45
- 164.501. Definitions.
Internet Only Manual (IOM), Medicare General Information, Eligibility, and Entitlement Manual (MGIEEM), Pub. 100-01
- Ch 4. §§ 10.9 and 10.9.1. Inpatient Psychiatric Facility Services Certification and Recertification.
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02
- Ch. 1. Inpatient Hospital Services Covered Under Part A.
- Ch. 2, §§ 10-90. Inpatient Psychiatric Hospital Services.
- Ch. 3, § 30. Inpatient Days Counting Toward Benefit Maximums.
- Ch. 4, §§ 10-50. Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation.
- Ch. 5, § 10.3. Availability of Reserve Days Where Psychiatric Limitations are Involved.
Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub.) 100-03
- Chapter (Ch.) 1, § 130. Mental Health.
- Ch. 1, § 130.1. Inpatient Hospital Stays for the Treatment of Alcoholism.
Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 3, § 190. Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).
- Ch. 23 Fee Schedule Administration and Coding Requirements.
Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3, § 188.8.131.52. Time Frames for Submission.
- Ch. 3, § 184.108.40.206. No Response or Insufficient Response to Additional Documentation Requests.
- Ch. 3, § 220.127.116.11. Signature Requirements.
- Ch. 3, § 18.104.22.168. Coding Determinations.
- Ch. 3, § 22.214.171.124. Denial Types.
- Ch. 6, § 6.5. Medical Review of Inpatient Hospital Claims for Part A Payment.
Related Local Coverage Determinations (LCDs)
- L33624. Psychiatric Inpatient Hospitalization. Effective 10/01/2015
- L33975. Psychiatric Inpatient Hospitalization. Effective 10/01/2015
- L34183. Psychiatric Inpatient Hospitalization. Effective 10/01/2015
- L34570. Psychiatric Inpatient Hospitalization. Effective 10/01/2015
Related Local Coverage Articles (LCAs)
- A55152. Psychiatric Inpatient Hospitalization revision to the Part A LCD. Effective 8/15/2016
- A56303. Psychiatric Inpatient Hospitalization revision to the Part A LCD. Effective 1/24/2019
- A56614. Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 6/20/2019
- A56865. Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 11/14/2019
- A57052. Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 9/26/2019
- A57726. Billing and Coding: Psychiatric Inpatient Hospitalization. Effective 10/3/2018
Last Updated Sep 20, 2022