Wiki Criteria for Inpatient/Outpatient facilities

[jwilkes@smartlightanalytics.com]

I am having difficulty finding the criteria for a patient seeking substance abuse treatment in an inpatient or outpatient setting. Do they have to have a certain amount of daily therapy to be considered inpatient/outpatient? Is it up to the provider's discretion, or is there a certain amount of therapy a patient must do before you can bill as a facility?

 

[TThivierge]

Hi Jwilkes,
The beh health patient will be referred to substance abuse treatment center or inpatient status facility by a LCSW, LPC or Psychiatrists or MD provider family doc or EMR doc. They have to document the reason why patient using dx blocks F10-19 and dx R45-R46 coupled with Depression F32 or PTSD F41, G47.30 or another ongoing condition. The documentation should list symptoms, ds, dates of past incidents, social HO and PFSH or future or current medications given. Patient assigned meds should be followed up every 30 days, also lab test given to prove alcohol or drug abuse. Some psych meds can cause dx E11 or lipid problems so should be monitored. Add ongoing problems with their beh health conditions. Psych patent are out of compliance if not take meds as assigned or try to go to differ psychiatrist doc or therapists docs get more medications. Dx Z91 vs Z53 blocks. Also check the CMS website for psych care guidelines
I hope I helped you
Lady T

 

[Pam Warren]

Where is the patient located? The volume of provider documentation is not going to determine the service location. If the patient is admitted to an inpatient setting, there would need to be an order for that level of care. This is because the payment for the facility varies based on what status the patient is in, and the patient's clinical status sometimes drives that level of care. For example, psychiatric inpatient services are paid based on IPPPS, and an outpatient treatment facility is paid via OPPS, but the patient may not be eligible for inpatient care, due to being able to be treated in an outpatient setting, or due to insurance refusal to pay for inpatient care. Knowing what place of service code to put on the 1500 form will depend on where the facility has placed the patient in terms of level of care. You'll need to find that out, because it is not based on the providers' intake, progress note or any other clinical notes. The patient's medical record should indicate the level of care. Lady T's comments above are helpful from a note content perspective, depending on whether a psychiatrist, psychologist or social worker is the provider. Occasionally, individual states and licensing boards will dictate the clinical requirements of those kinds of treatment facilities. So the hospital itself decides where the patient is admitted, and they will have clinical criteria. CMS has information also regarding their clinical requirements in certain settings, but it often doesn't align with your state Medicaid.

As far as the treatment plan, those are individualized and created specifically for each patient, based on their needs. Although SAT facilities typically have standardized programs, the timing and frequency of therapeutic interventions can vary, and isn't up to the coder to determine, since it would have no bearing on how the physician bills are submitted. What you need to know is under what status was the patient admitted (acute care or psychiatric inpatient, outpatient, provider based clinic, mental health facility or outpatient office) in order to assign your POS code, and then you code your provider visits based on individual documentation, for example, group therapy, individual therapy, etc., and/or initial or subsequent hospital visits, if applicable. Hope this helps.