UTILIZATION MANAGEMENT GUIDELINE COVERAGE GUIDELINE CODING RELATED POLICIES SCOPE ADDITIONAL INFORMATION HISTORY Behavioral Health: Psychiatric Residential Treatment Number 3.01.508 Effective Date February 10, 2015 Revision Date(s) 09/23/15; 02/10/15; 1/1/15; 12/22/14; 09/08/14; 08/11/14; 03/10/14; 03/08/13; 04/10/12; 05/10/11; 03/09/10; 05/12/09; 05/13/08; 03/11/08; 10/9/07; 03/13/07; 03/14/06; 03/08/05; 03/09/04; 04/15/03; 08/11-14 Replaces 3.01.502, 3.01.504, 3.01.505, and 3.01.506 Coverage Guideline Psychiatric residential treatment may be considered medically necessary when treatment is provided in a licensed psychiatric residential treatment or sub-acute treatment facility or a psychiatric residential treatment or sub-acute treatment unit in a licensed hospital, and the criteria listed below are met. Criteria Severity of Illness Criteria for Psychiatric Residential Treatment Admission At least one of the following must be present: a. One or more severe psychiatric disorders of several months or longer duration, causing significantly impaired functioning or behavioral dyscontrol that has been sustained over several months or longer, with failure to respond to less restrictive and intensive treatment interventions, or with escalation to the point that less restrictive and intensive treatment interventions are not likely to be successful. b. One or more severe psychiatric disorders of several months or longer duration, causing repetitive harm to self or others (not severe enough for inpatient admission), ongoing active risk of harm to self or others, or repetitive high risk behaviors that are highly likely to result in serious harm to self or others without 24/7 containment and treatment. c. One or more severe psychiatric disorders partially stabilized during inpatient psychiatric treatment or treatment in a crisis stabilization facility, but did not stabilize sufficiently for partial hospitalization or outpatient treatment and require continued treatment and supervision for further stabilization in a 24/7 structured setting. Additional Criteria for Psychiatric Residential Treatment Admission All of the following must be met: a. The purpose of the residential treatment admission is stabilization in the context of a short-term stay followed by transfer to a less restrictive level of care or to appropriate placement if sufficient stabilization is not achieved during a short-term stay. (Short-term is generally considered to be 90 days or less, or up to 150 days for clinically extenuating cases; lengthier projected lengths of stays are considered to be indications of intended long-term stays that are not consistent with the stated purpose of a residential treatment admission.) b. Residential treatment admission is not primarily due to involuntarily commitment, forensic evaluation, or other court-ordered stay in the absence of one of criteria (a) through (c) above.
c. The presenting psychiatric symptoms/impairments are not primarily the result of active substance abuse/addiction/intoxication/withdrawal. d. There is reason to expect, based on history and clinical presentation that clinical improvement is likely during a course of short-term psychiatric residential treatment, and that improvement can be sustained in a less restrictive/intensive level of care following discharge from residential treatment. e. The patient has sufficient cognitive capacity to participate in, utilize, and benefit from psychiatric residential treatment. f. If there have been one or more previous episodes of psychiatric residential treatment, an explanation is provided of why previous residential treatment failed to be effective, or why improvement during residential treatment was not able to be maintained following discharge from residential treatment, and what is going to be different about another episode of psychiatric residential treatment such that it is expected to result in improvement during residential treatment and sustained maintenance of improvement following discharge from residential treatment. g. Admission to psychiatric residential treatment Is not due to transfer from another residential or sub-acute treatment facility (psychiatric or chemical dependency/substance abuse) unless significantly impaired functioning or behavioral dyscontrol, repetitive harm to self or others, ongoing active risk of harm to self or others, or repetitive high risk behaviors that are highly likely to result in serious harm to self or others without 24/7 containment, are still present at the time of transfer, with no or minimal or inadequate improvement during the preceding residential or subacute treatment stay, and transfer is for specialized clinical services that are medically necessary, were not available at the preceding residential or sub-acute treatment facility, and can be provided in a short-term stay. h. Admission to psychiatric residential treatment is not due to transfer from a wilderness or adventure or camping program or expedition unless significantly impaired functioning or behavioral dyscontrol, repetitive harm to self or others, ongoing active risk of harm to self or others, or repetitive high risk behaviors that are highly likely to result in serious harm to self or others without 24/7 containment, are still present at the time of transfer, with no or minimal or inadequate improvement during the wilderness or adventure or camping program or expedition. i. The location of treatment is not any type of wilderness or adventure or camping program or expedition, boarding school or therapeutic boarding school, boot camp, military school or academy, group home, therapeutic home, or supported or alternative housing. j. Residential treatment is not being utilized as an alternative to incarceration, specialized school placement, specialized housing, or respite for family or community. k. Residential treatment is not being utilized for long-term placement due to lack of available or adequate supportive living settings in the community. l. The primary reason for residential treatment admission is not a legal, financial, housing, or social problem in the absence of one or more major psychiatric disorders meeting one or more severity of illness admission criteria (a) through (c) above. Severity of Illness Criteria for Continued Stay At least one of the following must be present: a. Significantly impaired functioning or behavioral dyscontrol continues to be present at a severity that requires 24/7 containment and treatment, or continued repetitive harm to self or others or active risk of harm to self or others continues to be present at a severity that requires 24/7 containment and treatment, or sufficient stabilization for partial hospitalization or outpatient treatment has still not occurred following step-down from inpatient treatment or treatment in a crisis stabilization facility. However, clinical progress must also be evident. If the stay reaches thirty days without clinical progress, then beginning improvement must be evident within an additional seven days, followed by observable clinical progress in symptom reduction, functional improvement, or improvement in behavioral control every seven to ten days. Increased participation in treatment, increased attendance at treatment activities, increased compliance with treatment recommendations, increased compliance with facility/program rules, increased completion of assignments, increased openness, building trust, increased discussion of problems or issues, increased insight, exploring or working on past or present issues, improving relationships, or similar processes, are not considered to be clinical progress in the absence of symptom reduction, functional improvement, or improvement in behavioral control. b. Sufficient stabilization for partial hospitalization or outpatient treatment has occurred, but a very brief additional period (five to seven days) of residential treatment is indicated (1) to ensure that
stabilization can be maintained without significant decompensation or (2) to secure an appropriate living placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. c. Maximum likely improvement has been achieved, there is little likelihood of further clinical improvement with continued residential treatment, but a very brief additional period (five to seven days) of residential treatment is needed to secure an appropriate placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. d. Little or no improvement has been achieved, there is little likelihood of clinical improvement with continued residential treatment, but a very brief additional period (five to seven days) of residential treatment is needed to secure an appropriate placement for a patient who will rapidly be readmitted if not discharged directly to such placement. Additional Criteria for Continued Stay All of the following must be met: a. The purpose of the residential treatment stay continues to be stabilization in the context of a short term stay followed by transfer to a less restrictive level of care or to appropriate placement if sufficient stabilization is not achieved during a brief stay. b. There must be reasonable likelihood, based on clinical information that continued residential treatment has the potential to result in (further) clinical improvement. Continued inability to improve will generally be considered as evidence that this is no longer the case and that continued psychiatric residential treatment is therefore no longer indicated (except for severity of illness continued stay criteria (c) and (d) above). c. The patient is attending most or all treatment activities, is actively participating in treatment, is demonstrating motivation to improve, and is actively attempting to utilize treatment to achieve clinical progress. d. Continued psychiatric symptoms/impairments are not primarily the result of active substance abuse/addiction/intoxication/withdrawal. e. Continued residential treatment is not primarily for containment or to prevent regression because there has been minimal or no improvement and there is little likelihood of clinical improvement with continued residential treatment (except for severity of illness continued stay criterion (d) above). f. Continued residential treatment is not primarily for containment or to prevent regression because clinical progress has stalled, or a new or chronic baseline has been reached, or maximum likely improvement has been achieved, and there is little likelihood of further clinical improvement with continued residential treatment (except for severity of illness continued stay criterion (c) above). g. Continued residential treatment is not primarily due to lack of adequate family, peer, community, or other external supports (in that case, alternative placement should be sought and secured within five to seven days as per severity of illness continued stay criteria (b), (c), or (d) above). h. Continued residential treatment is not primarily due to lack of a place for the patient to reside (except for severity of illness continued stay criteria (b), (c), or (d) above). i. Continued residential treatment is not primarily due to waiting for a placement to be identified or secured (except for severity of illness continued stay criterion (b), (c), or (d) above). j. Continued residential treatment is not primarily due to waiting for funding for a placement (except for severity of illness continued stay criterion (b), (c), or (d) above). k. Continued residential treatment is not primarily due to waiting for acceptance by, bed availability at, funding for, or transfer to another treatment setting, e.g. a different RTC; a chemical dependency facility (except for severity of illness continued stay criterion (b), (c), or (d) above). l. Continued residential treatment is not primarily due to waiting for the date of enrollment or starting in a school, vocational, treatment, or other program. m. Continued residential treatment is not primarily due to an involuntary commitment, forensic evaluation, or other court-ordered stay in the absence of one of severity of illness continued stay criteria (a) through (d) above. n. Continued residential treatment is not primarily due to waiting for a discharge plan to be determined or worked-on or completed. o. Continued residential treatment is not primarily due to waiting for a court-order or approval in order to be released. p. Continued residential treatment is not primarily due to unavailability or refusal of family, friends, or other persons to pick-up the patient. q. Continued residential treatment is not primarily due to unavailability of, or difficulties or delays in
arranging for, transportation to home/community, another treatment facility, a placement, or other discharge location. r. Continued residential treatment is not primarily because of a pending change in or uncertainty about family structure, e.g. a pending or possible separation or divorce, or for children and adolescent patients, a pending change in or uncertainty about custody or guardianship. s. Continued inpatient stay is not primarily to delay or avoid incarceration. t. Continued residential treatment is not primarily for respite for family or community. u. Continued residential treatment is not primarily for the treatment of substance abuse or chemical dependency, or to prevent access to abuseable/addictive substances. (Treatment in an approved substance abuse/chemical dependency treatment setting may be appropriate.) v. Continued residential treatment is not primarily due to patient non-compliance with treatment orders, treatment recommendations, or treatment activities, inadequate or non-participation in treatment, or inadequate/absent participation in discharge planning, unless such compliance or participation difficulties are a direct consequence of psychiatric symptomatology that is being actively addressed in treatment. w. For children or adolescents, continued stay is not primarily because parents/guardians are not agreeing to treatment recommendations, are not adequately participating in treatment, or are not agreeing to or cooperating with discharge planning. x. Continued residential treatment is not primarily to work on long-standing or long-term issues or goals (working on long-standing or long-term issues or goals does not constitute short term stabilization). y. Continued residential treatment is not primarily to start or continue a course of psychotherapy that will most likely be long-term therapy. z. Continued residential treatment is not primarily for psychotherapeutic work that has the potential to cause a worsening of symptoms (e.g. some forms of trauma work, even if past trauma is believed to be contributory to the patient s psychiatric condition). aa. Continued residential treatment is not primarily to ensure that a certain level of stabilization or improvement can be maintained for an extended period of time prior to discharge. One to two weeks of a level of clinical stability or improvement that can be managed at a less restrictive level of care is considered to be sufficient for discharge from residential treatment. bb. A return to a residential treatment facility following a wilderness or adventure or camping component or program or expedition does not constitute medically necessary continued residential treatment unless significantly impaired functioning or behavioral dyscontrol, repetitive harm to self or others, ongoing active risk of harm to self or others, or repetitive high risk behaviors that are highly likely to result in serious harm to self or others without 24/7 containment, are still present at the time of return, with no or minimal or inadequate improvement during the wilderness or adventure or camping component or program or expedition. Intensity of Service Criteria for Psychiatric Residential Treatment Admission and Continued Stay All of the following must be present: a. There must be an attending psychiatrist or psychiatric nurse practitioner who is in charge of treatment. b. A thorough psychiatric admission evaluation by the attending psychiatrist or psychiatric nurse practitioner, including history, full mental status examination, initial diagnostic assessment, and initial treatment plan, must be completed within 48 hours of admission. c. A thorough physical exam must be completed by the attending psychiatrist, psychiatric nurse practitioner, or by a physician, nurse practitioner, or physician assistant designated by the attending psychiatrist or psychiatric nurse practitioner, within seven days of admission unless completed within seven days prior to admission and provided to the residential treatment program. In addition, any necessary laboratory, radiologic, or other evaluations must be obtained in a timely manner. d. A comprehensive, individualized, realistic multi-disciplinary treatment plan that focuses primarily on stabilization must be completed within seven days of admission. The target symptoms, functional impairments, and behaviors which require stabilization must be clearly identified, the goals of residential treatment must be presented in measurable terms, and a timeframe must be clearly established for accomplishing those goals. 1. The treatment plan and the treatment provided must be individualized for the patient and
not determined by any type of standardized program, any pre-set number of program days, or reaching a certain chronological age. 2. If the clinical presentation is so complex and unclear that ancillary evaluation (e.g. psychological testing, neurological evaluation) is required prior to being able to complete a comprehensive treatment plan, all necessary ancillary evaluations and the comprehensive treatment plan must be completed no later than fourteen days after admission. e. The attending psychiatrist or psychiatric nurse practitioner must assess the patient's condition, progress, and continued treatment needs in-person, one-on-one, at least once every seven days. In addition, the attending psychiatrist or psychiatric nurse practitioner must be available to the program/facility by phone 24/7 when not on-site. f. For child and adolescent patients, for patients 18 and older who are residing with a parent or parents, and for patients for whom it is determined that family issues/dynamics/conflict are a significant contributor to the patient s acute difficulties, there must be active family involvement as follows: a minimum of one family therapy session or equivalent professionally-facilitated family treatment activity on-site at least once weekly, with a greater frequency (e.g. two to three times weekly) when clinically indicated, unless it can be clearly demonstrated that family therapy/treatment involvement would adversely impact clinical outcome. Telephonic or video sessions may be utilized in lieu of on-site sessions if the family resides more than a three hour one-way drive from the facility (estimated driving time takes into account weather or other delays). When telephonic or video sessions are utilized in lieu of on-site sessions, increased frequency of sessions (e.g. two to three times weekly) may be required to compensate for the absence of onsite family work. Multi-family groups are not acceptable for meeting this requirement. g. Unless medically contraindicated or there is a valid clinical reason for a delay, psychotropic medication must be rapidly initiated for conditions or symptom constellations known to be potentially medication-responsive. h. If there is co-morbid substance abuse or chemical dependency, the treatment plan must reflect interventions for cessation of substance abuse, and for continued substance use treatment or relapse prevention after discharge.. i. Concurrent medical or surgical problems, if significant or if potentially interfering with assessment or treatment, must be evaluated and treated in a timely fashion. Failure to access consultative medical-surgical resources in a timely fashion is not by itself adequate grounds for extending length of stay. j. An initial discharge plan must be formulated within seven days of admission. Subsequent to that, active, appropriate, realistic, comprehensive discharge planning must be initiated in a timely fashion and must continue throughout the residential stay until completed. Discharge planning may not be delayed until the patient is clinically ready for discharge. Discharge planning must include early identification of the level of care and/or services, provider types, and other resources that will be needed post-discharge, including family and community supports and resources as appropriate. There must be evidence of ongoing activity to locate and secure post-discharge treatment resources. Appropriate follow-up or post post-discharge facility treatment must be scheduled or arranged and must be timely. If discharge to home/family is not an option, then alternative placement options must be rapidly identified, and there must be active efforts to locate and secure placement. The facility must take primary responsibility for carrying-out and completing discharge planning, and may not expect the patient or family/ guardians to seek and secure follow-up arrangements or placement beyond what the patient or family/guardians are realistically capable of doing and willing to do in a timely manner. The discharge plan may be modified if necessitated by a significant change in the patient s clinical condition or by failure to improve to the extent that had been anticipated. k. Failure to improve within clinically expected timeframes must lead to a reassessment of either the diagnoses and/or the treatment plan, and an appropriate revision of the treatment plan. l. The patient must be involved in active treatment activities or interventions during a majority of waking hours, 7 days/week (residential treatment is not for respite, relaxation, recreation, or rest). The following services must be provided throughout the residential stay: 1. Staff supervision 24/7. 2. Skilled nursing care on-site daily during normal patient waking hours, and available when needed 24/7. 3. Clinical assessment at least once daily.. 4. Individual psychotherapy at least once weekly, and more frequently (e.g. two to three times weekly) when clinically indicated. 5. Group psychotherapy and/or milieu therapeutic activities several hours daily. m. Therapeutic passes may be appropriate, when discharge is anticipated within one to two weeks
and the discharge plan is for discharge to home or other community setting (1) for evaluating patients' readiness for discharge by assessing their ability to function at home and in the community, or (2) for providing a less-abrupt transition back to home and community (e.g. via partial day attendance at school or work). For child and adolescent patients, passes must be with a parent, guardian, custodian, or other responsible adult. A maximum of one or two successful partial day passes, full day passes, or overnight (1-2 nights) passes is sufficient, and discharge is then expected within seven days of completion. Passes which exceed these parameters will be considered to be conclusive evidence that residential treatment is no longer medically necessary. Coding CPT Number Description 90785 Interactive complexity (List separately in addition to the code for primary procedure) 90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services 90832 Psychotherapy, 30 minutes with patient and/or family member 90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90834 Psychotherapy, 45 minutes with patient and/or family member 90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90837 Psychotherapy, 60 minutes with patient and/or family member 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90846 Family psychotherapy (without the patient present) 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) 90849 Multiple-family group psychotherapy 90853 Group psychotherapy (other than of a multiple-family group) 96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report 96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face 96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report 96118 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report 96119 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face 96120 Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report HCPCS Number Description T2048 Behavioral health; long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem.
Related Guidelines / Policies 3.01.516 Behavioral Health: Psychiatric Inpatient Treatment Scope Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Additional Information References 1. Characteristics of Residential Treatment for Children and Youth with Serious Emotional Disturbances: Abt Associates for The National Association of Children s Behavioral health (NACBH) and National Association of Psychiatric Health Systems (NAPHS), Summer 2008. 2. Family-centered Residential Treatment: Knowledge, Research, and Values Converge. Walter, Uta M.; Petr, Christopher G. Residential Treatment for Children. Vol. 25(1), 2008, 1-16. 3. Principles of Care for the Treatment of Children and Adolescents With Mental Illness in Residential Treatment Centers, American Academy of Child and Adolescent Psychiatry (AACAP) 2010. 4. R Epstein. Inpatient and residential treatment effects for children and adolescents: a review and critique. Child and Adolescent Psychiatric Clinics of North America. 2004,13,2:411-428. History Date Reason 4/15/03 Add to Mental Health Section - New medical policy, converted from Care Management policy. 03/09/04 Replace Policy - Scheduled review; no change to policy statement. 09/01/04 Replace Policy - Policy renumbered form PR.3.01.106. No date changes. 03/08/05 Replace Policy - Scheduled review; no change to policy statement. 03/14/06 Replace Policy - Scheduled review; CPT codes updated; no change to policy statement. 06/16/06 Update Scope and Disclaimer - No other changes. 03/13/07 New PR Policy - Policy expanded to incorporate multiple mental health and chemical dependency/substance abuse levels of care, replacing PR.3.01.502, PR.3.01.504, PR.3.01.505, and PR.3.01.506. Policy statements for medically necessary treatment for psychiatric care, eating disorders, PHP, RTC and IOP all approved when InterQual criteria are met; substance abuse considered medically necessary when InterQual criteria are met, noting that some plans follow ASAM criteria; psychological and neuropsychological testing approved when InterQual criteria and test times per test publishers are met. References added and codes updated. 10/9/07 Replace Policy - Policy statement for psychiatric residential treatment expanded; Medically necessary when InterQual criteria are met and additional criteria when applicable; references updated and codes updated. 03/11/08 Replace Policy - Scheduled review; no change to policy statement.
05/13/08 Replace Policy - Policy updated with literature search. Policy statement updated to include under the medically necessary criteria regarding chemical dependency or substance abuse. This includes detoxification services for alcohol or chemical dependency. Reference added. 05/12/09 Replace Policy - Policy updated with literature search; three policy statements deleted and now only include psychiatric RTC. Title updated to Psychiatric Residential Treatment and deleted Medical Necessity for Behavioral Health Services. Reviewed by Dr. Small. Reference added. 03/09/10 Replace Policy - Policy updated with literature search; no change to the policy statement. Reviewed by Dr. Small. 05/10/11 Replace Policy - Policy reviewed by Dr. Small. No change to policy statement. 04/25/12 Replace policy. Policy updated with reference to Milliman Care Guidelines, replacing InterQual Criteria. No change in policy statement. 03/08/13 Replace policy. Milliman Care Guidelines 16 th edition still in force. Policy reviewed by practicing psychiatrist. No change to policy statement. 03/25/14 Replace policy. Policy reviewed by practicing licensed psychiatrist. No change in policy statement. Coding updated; deleted CPT codes 90801, 90816 90829, 90857 and 90862 removed from the policy. CPT Codes 90785 and 90832 90838 added which replace the previous codes. 08/11/14 Interim review. Policy updated to include coverage criteria within the Policy section; reference to MCG criteria removed. 09/08/14 Interim review. Additional criterion added to first medically necessary statement: If there is a history of prior RTC stays, the reasons for additional therapy should be clear, including identifying and addressing factors which contributed to the failure of the prior course of therapy. 12/22/14 Interim review. Reference #1 removed. 1/13/15 Annual review. Policy converted to UM Guideline template. Guideline rewritten and reorganized. Individual guidelines developed for particular types of treatment and extracted. Title reordered to read, Behavioral Health: Psychiatric Residential Treatment. 02/10/15 Interim update. Additional criteria added to indicate that treatment is not an alternative to incarceration or to be utilize as an alternative to respite for family/community and patient must be actively participating in treatment/discharge planning as appropriate for their condition. It was also added that, for pediatric patients, parents/guardians must be actively participating in and agree to treatment/discharge planning. 09/23/15 Coding update. HCPCS code T2048 added to policy. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2015 Premera All Rights Reserved.