Checklist to Help Ensure Compliant Certifications for Inpatient Psychiatric Hospitalizations

Incomplete certifications may derail Medicare claims for inpatient psychiatric hospitalizations.[1] This checklist, which is based on Medicare requirements, was developed by Georgia Rackley, senior clinical specialist with SunStone Consulting in Harrisburg, Pennsylvania. Contact her at georgiarackley@sunstoneconsulting.com.

Medicare Psychiatric Inpatient Certification: Audit Tool

Certification

Findings

Order for inpatient admission signed and dated by a physician.

Certification statement that services can reasonably be expected to improve the patient’s condition or for diagnostic study (e.g., a facility-based form) incorporated into the initial psychiatric admission evaluation or a progress note.

  • Completed, signed and dated on admission by a physician.

Recertification

Findings

First recertification completed by day 12 of the inpatient stay; timing of subsequent recertifications per facility’s utilization review committee, on a case-by-case basis, but no less than every 30 days.

Statement that services were and continue to be required for treatment that can reasonably be expected to improve the patient’s condition, or for diagnostic study; the patient continues to need, on a daily basis, active treatment furnished directly by, or requiring the supervision of, inpatient psychiatric facility personnel.

  • Recertification statement is found on a facility-based form and/or incorporated into a progress note.

Patient medical record supports active treatment:

  • Individualized treatment plan with diagnoses, short- and long-term goals, specific treatment modalities used, and responsibilities of each member of the treatment team.

  • Progress notes by all disciplines document the patient’s response to treatment and progress relative to treatment plan goals.

  • Evidence that patient’s treatment is supervised and evaluated by a physician (e.g., participation in treatment planning conferences, visits with the patient, discussions with therapists).

Physician Progress Notes

Findings

Physician progress notes support the continuance of the inpatient stay to include, as applicable:

  • The need for continuous 24-hour medical/behavioral care and management in a behavioral health milieu.

  • How patient symptoms still meet admission criteria (e.g., ongoing psychosis, depression, suicidality, aggression, self-harm, inability to care for self, inability to safely function in a less restrictive setting).

  • Development of any new symptoms.

  • Patient’s response to medication and therapies relative to the individualized treatment plan.

  • Describe the high probability of relapse or decompensation if patient is not afforded further hospitalization for stabilization and treatment.

  • Describe the lack of adequate/effective supports to maintain patient safely and/or stability in a less restrictive setting.

  • Describe the lack of an appropriate aftercare plan that meets the medical/behavioral healthcare needs.

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