Psychiatric Partial Hospitalization: An Overview. By: Cherilyn G. Murer, JD, CRA

Transcription

1 Psychiatric Partial Hspitalizatin: An Overview By: Cherilyn G. Murer, JD, CRA Intrductin Hspitalizatin fr psychiatric illness has undergne revlutinary changes in the last three decades. At mid-century, there were tw basic surces f care fr peple with mental illnesses: a psychiatrist's private ffice r a mental hspital. Thse wh went t the hspital ften stayed fr many mnths, even years. Tday peple with a mental illness have many treatment ptins depending upn medical need: 24-hur inpatient care in general hspital psychiatric units, private psychiatric hspitals, state and federal public psychiatric hspitals and Veterans Administratin (VA) hspitals; partial hspitalizatin r day care; residential care; cmmunity mental health centers; care in the ffices f psychiatrists and ther mental health practitiners, and supprt grups. In all these settings, health care prfessinals wrk very hard t prvide care accrding t a treatment plan develped by each patient's psychiatrist. The gal is t restre maximum independent living as rapidly as pssible, using the apprpriate level f care fr the apprpriate illness. Psychiatric Partial Hspitalizatin Once psychiatric treatment stabilizes a patient's cnditin, he r she may prgress t a less-intensive treatment setting. The psychiatrist may recmmend partial hspitalizatin. A partial hspitalizatin prgram ( PHP ) is an intensive psychiatric utpatient treatment which prvides less than 24 hurs f daily care which is designed t prvide patients with severe mental health cnditins an individualized and attentive treatment prgram that is nt typically prvided in a regular utpatient setting. The PHP ptin is nt limited t peple wh are ending a hspital stay; it als meets the needs f peple wh live in the cmmunity and need a higher level f care withut the services f vernight, 24-hur nursing. Partial hspitalizatin prvides individual and grup psychtherapy, scial and vcatinal rehabilitatin, ccupatinal therapy, assistance with educatinal needs, and ther services t help patients maintain their abilities t functin at hme, at wrk and in scial circles. Hwever, because their treatment setting helps them t develp a supprt netwrk f friends and family that can help mnitr their cnditins when they are nt in the hspital, they can return hme

2 at night and n weekends. Partial hspitalizatin r day treatment wrks best fr peple whse symptms are under cntrl. They enter care directly frm the cmmunity r after being discharged frm 24-hur care. Partial hspitalizatin is mst effective fr patients wh are ready fr therapy and rehabilitatin that can mve them cmfrtably back int the cmmunity. Partial Hspitalizatin Prgram Medicare Criteria T The PHPs wrk best as part f a cmmunity cntinuum f mental health services which range frm the mst restrictive inpatient hspital setting t less restrictive utpatient care and supprt. Prgram bjectives shuld fcus n ensuring imprtant cmmunity ties and clsely resemble the real-life experiences f the patients served. PHPs may be cvered under Medicare when they are prvided by a hspital utpatient department r a Medicare-certified cmmunity mental health clinic. Partial hspitalizatin is active treatment that incrprates an individualized treatment plan which describes a crdinatin f services wrapped arund the particular needs f the patient, and includes a multidisciplinary team apprach t patient care under the directin f a physician. The prgram reflects a high degree f structure and scheduling. Accrding t current practice guidelines, the treatment gals shuld be measurable, functinal, time-framed, medically necessary, and directly related t the reasn fr admissin. A prgram cmprised primarily f diversinary activity, scial, r recreatinal therapy des nt cnstitute a PHP. Psychscial prgrams which prvide nly a structured envirnment, scializatin, and/r vcatinal rehabilitatin are nt cvered by Medicare. A prgram that nly mnitrs the management f medicatin fr patients whse psychiatric cnditin is therwise stable, is nt the cmbinatin, structure, and intensity f services which make up active treatment in a PHP. Medicare Cverage As stated abve, PHPs are structured t prvide intensive psychiatric care thrugh active treatment. T be eligible fr PHP, a patient must be under the care f a physician wh certifies the medical necessity fr partial hspitalizatin. The certificatin must indicate that, but fr PHP, the patient wuld require inpatient psychiatric hspitalizatin. There are tw patients wh fall under this categry: (1) thse patients discharged frm an inpatient hspital treatment prgram, and the PHP is in lieu f cntinued inpatient treatment, r (2) thse patients wh, absent PHP, wuld require inpatient hspitalizatin.

3 The certificatin shuld als identify the diagnsis and medical necessity fr PHP. A prper diagnsis invlves an Axis I mental disrder, with a level f functining belw 40. Medical necessity is shwn by patients that require supervisin and crdinatin because f a mental disease which severely interferes with multiple areas f daily life, including scial, vcatinal, r educatinal functining. This dysfunctin must be f an acute nature. There must als be a reasnable expectatin f imprvement in a patient s disrder and level f functining as a result f the active PHP treatment. The written certificatin must be recertified by the treating physician n the eighteenth calendar day fllwing admissin t the PHP, and at least every thirty days thereafter. The recertificatin must indicate that, absent PHP, the patient wuld require inpatient care. It must als include infrmatin regarding the patient s respnse t treatment, the cntinuing symptms, and the treatment gals t facilitate discharge frm the prgram. Treatment must be pursuant t an individualized written plan f care created by the admitting physician. Active PHP treatment includes clinically recgnized therapeutic interventins, including grup and family psychtherapy sessins, ccupatinal, activity, and psycheducatinal grups pertinent t the patient s illness. Psychiatric diagnstic evaluatins and medicatin management are als cnsidered reasnable and necessary. As active treatment is prvided, the patient s medical recrd must clearly and accurately present prgress ntes reflecting the nature f treatment received, the patient s respnse, and the treatment s relatinship t the verall treatment plan gals. There are several listed cvered services, but the imprtant issue is that a physician prperly dcument evaluatins, treatment plans, treatment per the plan, and prgress. Such dcumentatin is necessary t demnstrate that PHP is reasnable and necessary. Furthermre, in the utpatient setting, the treating physician must supervise all services. Medicare Dcumentatin Requirements As discussed abve, the fllwing cmpnents will be used t help determine whether the PHP services prvided were accurate and apprpriate and whether they will be reimbursed by Medicare and the details are summarized in the fllwing chart: 1. Initial Psychiatric Evaluatin/Certificatin 2. Physician Recertificatin 3. Treatment Plan 4. Prgress Ntes

4 MEDICARE DOCUMENTATION REQUIREMENTS Prepared by: Murer Cnsultants, Inc. Initial Psychiatric Evaluatin/Certificatin Physician Recertificatin Requirements Upn admissin, a certificatin by the physician must be made that the patient admitted t the PHP wuld require inpatient psychiatric hspitalizatin if the partial hspitalizatin services were nt prvided. The certificatin shuld identify the diagnsis and psychiatric need fr the partial hspitalizatin. Partial hspitalizatin services must be furnished under an individualized written plan f care, established by the physician, which includes the active treatment prvided thrugh the cmbinatin f structured, intensive services that are reasnable and necessary t treat the presentatin f serius psychiatric symptms and t prevent relapse r hspitalizatin. Signature The physician recertificatin must be signed by a physician wh is treating the patient and has knwledge f the patient s respnse t treatment. Timing The first recertificatin is required as f the 18th calendar day fllwing admissin t the PHP. Subsequent recertificatins are required at intervals established by the prvider, but n less frequently than every 30 days. Cntent The recertificatin must specify that the patient wuld therwise require inpatient psychiatric care in the absence f cntinued stay in the PHP and describe the fllwing: The patient s respnse t the therapeutic interventins prvided by the PHP; The patient s psychiatric symptms that cntinue t place the patient at risk f hspitalizatin; and Treatment gals fr crdinatin f services t facilitate discharge frm the PHP. Treatment Plan Partial hspitalizatin is active treatment pursuant t an individualized treatment plan, prescribed and signed by a physician, which identifies treatment gals, describes a crdinatin f services, is structured t meet the particular needs f the patient, and includes a multidisciplinary team apprach t patient care. The treatment gals described in the treatment plan shuld directly address the presenting symptms and are the basis fr evaluating the patient s respnse t treatment. Treatment gals shuld be designed t measure the patient s respnse t active treatment. The plan shuld dcument nging effrts t restre the individual patient t a higher level f functining that wuld permit discharge frm the prgram, r reflect the cntinued need fr the intensity f the active therapy t maintain the individual s cnditin and functinal level and t prevent relapse r hspitalizatin. Prgress Ntes Sectin 1833(e) f the Scial Security Act prevents Medicare frm paying fr services unless necessary and sufficient infrmatin is submitted that shws that services were prvided and t determine the amunts due. A prvider may submit prgress ntes t dcument the services that have been prvided. The prgress nte shuld include a descriptin f the nature f the treatment service, the patient s respnse t the therapeutic interventin and its relatin t the gals indicated in the treatment plan. Murer Cnsultants 7/07

5 Ultimately, psychiatric partial hspitalizatin is anther key venue in the psychiatric cntinuum f care. It is imprtant fr health care prviders t be aware f this ptin and t knw hw t ensure full cmpliance with the Medicare mandates surrunding partial hspitalizatin prgrams. Abut the Authr: Cherilyn G. Murer, J.D., C.R.A. is CEO and funder f the Murer Grup, a legal based healthcare management cnsulting firm in Jliet, IL, specializing in strategic analysis and business develpment. Ms. Murer may be reached at (815) r viewed n her web site: