Download Inpatient Documentation

DEPARTMENT OF HEALTH CARE SERVICES
PROGRAM OVERSIGHT & COMPLIANCE BRANCH
IMPROVING DOCUMENTATION FOR
ACUTE PSYCHIATRIC INPATIENT
HOSPITAL SERVICES
THE MEDI-CAL SPECIALTY MENTAL HEALTH
SERVICES PROGRAM
August/September 2015
1
IMPROVING INPATIENT DOCUMENTATION
AGENDA
1. Statutory, Regulatory and Contractual Bases for Oversight
2. The Language We Use
3. Medical Necessity Criteria for Admission
a)
b)
c)
d)
e)
Diagnosis
Indications for Admission/Impairment Criterion
Focus of Treatment Requirement
Level of Care Requirement
Efficacy Requirement
4. Medical Necessity for Continued Stay Services
a)
b)
Indications
Guidance and Recommendations
2
IMPROVING INPATIENT DOCUMENTATION
5. Plans of Care
a)
b)
Requirements: Federal and Contractual
Guidance and Recommendations
6. Administrative Day Services
a)
b)
Documentation Requirements
Guidance and Recommendations
7. A Reminder Regarding Interpreter Services
8. Examples of Documentation Deficiencies and Some
Recommendations
3
IMPROVING INPATIENT DOCUMENTATION
• INTRODUCTION
• The information in this PowerPoint is based on:
• (1) The triennial reviews of the 18 Short-Doyle/MediCal acute psychiatric inpatient hospitals; and
• (2) The adjudication of second level Treatment
Authorization Request (TAR) appeals.
• Between these two areas, we review
documentation for approximately 4,500 inpatient
hospital days per year.
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IMPROVING INPATIENT DOCUMENTATION
•
Pursuant to Section 1810.380 of Title 9 of the California Code of Regulations (CCR), the
State Department of Health Care Services (DHCS) is responsible for monitoring the 18
Short-Doyle/Medi-Cal acute psychiatric inpatient hospitals and the Mental Health Plans
(MHPs) with which they are associated to ensure their compliance with the provisions of
the following:
•
Section 1820.205 of CCR Title 9, “Medical Necessity Criteria for Reimbursement of
Psychiatric Inpatient Hospital Services”
•
Section 1820.220 of CCR Title 9, “MHP Payment Authorization by a Point of
Authorization”
•
Section 1820.230 of CCR Title 9, “MHP Payment Authorization by a Utilization Review
Committee”
•
Sections 5325.1 and 5325.1(a) of the Welfare and Institutions Code, “Same Rights and
Responsibilities Guaranteed Others; Discrimination by Programs or Activities Receiving
Public Funds; Additional Rights”
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IMPROVING INPATIENT DOCUMENTATION
• Section 456.180 of Title 42 of the Code of Federal
Regulations, “Individual Written Plan of Care”
• Sections 456.201 through 456.238 of Title 42 of the Code of
Federal Regulations, Requirements for Utilization Review
Plans
• Sections 456.241 through 456.245 of Title 42 of the Code of
Federal Regulations, Requirements for Medical Care
Evaluation Studies
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IMPROVING INPATIENT DOCUMENTATION
• Provisions of the contract between DHCS and the MHPs
Table 2 - Included ICD-9 Diagnoses - Hospital Inpatient Place of Service
290.12 – 290.21
299.10 - 300.15
308.0 – 309.9
290.42 – 290.43
300.2 - 300.89
311 – 312.23
291.3
301.0 - 301.5
312.33 - 312.35
291.5 - 291.89
301.59 - 301.9
312.4 – 313.23
292.1 - 292.12
307.1
313.8 – 313.82
292.84 – 292.89
307.20 - 307.3
313.89 - 314.9
295.00 – 299.00
307.5 - 307.89
787.6
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IMPROVING INPATIENT DOCUMENTATION
• In addition, DHCS is responsible for monitoring the MHP
Points of Authorization to ensure that they are processing
Treatment Authorization Requests (TARs) in accordance with
Section 438.210 of Title 42 of the Code of Federal
Regulations as part of the triennial system reviews, and also
receives and adjudicates second level TAR appeals from feefor-service acute psychiatric inpatient hospitals.
8
THE LANGUAGE WE USE
• The biggest problems reviewers encounter is
documentation which is:
– Unclear
– Vague
– Not Behaviorally Specific
• You should:
– AVOID JARGON
– USE LANGUAGE WHICH IS BEHAVIORALLY
SPECIFIC
– USE VERBS RATHER THAN ADJECTIVES
– MAKE SURE WHAT YOU WRITE IS CLEAR
9
Example of a Note Using Jargon
The patient was impulsive and aggressive during
community meeting, and exhibited poor impulse
control on at least three occasions. Following group, the
patient approached the nursing station, posturing
aggressively, and spoke to the charge nurse in a
threatening manner. His mood was labile, his behavior
unpredictable. When redirected, he returned to the day
room where he was noted to be sullen. After
approximately 15 minutes, the patient became sexually
inappropriate and had to be asked to return to his
room. He continued to be disruptive for the remainder
of the shift.
10
THE LANGUAGE WE USE
• Despite the fact that this paragraph contains six
syntactically and grammatically correct sentences, it
conveys very little precise meaning.
• What do we really know about the patient’s behavior
from this note?
• Was the patient a danger to others? Gravely
disabled?
11
THE LANGUAGE WE USE
•
Here is the same note rewritten in behaviorally specific language:
The patient interrupted the social worker leading the
community meeting three times, and when asked to wait
until the “Open Discussion” part of the meeting, he kicked
at the empty chair in front of him. After group the patient
came to the nursing station and, pointing his finger at the
refrigerator, asked if he could have his morning snack.
When told that the snack would be ready in 10 minutes,
he went to the day room and sat silently, staring toward
the nursing station. After 15 minutes, an aide reported
that the patient was rubbing his genital region with his
hand. He continued to ask questions at the nursing
station throughout the morning, usually regarding the next
smoke break, snack or meal.
12
THE LANGUAGE WE USE
•
Here are a few examples of behaviorally non-specific words/phrases and their
behaviorally specific counterparts:
DON’T WRITE THIS
THIS WOULD BE BETTER
Impulsive
Acts without anticipating consequences as exhibited by
grabbing items from other patients’ hands.
Aggressive
Shoved other patients out of the cafeteria line so that he
could be served first.
Postured Aggressively
Shook a closed fist in the therapist’s face.
Threatening
She said, “If you ask me another question I will slap you.”
Hostile
He shouted, “Go to Hell” when he was asked to join the
therapy group.
+HI
Describe the ideation. Is it active or passive? Is it
directed at a particular person? Is it directed at an
identifiable group of people? Is it accompanied by
homicidal intent? Is there a specific plan? Opportunity?
Means? Timing?
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THE LANGUAGE WE USE
DON’T WRITE THIS
THIS WOULD BE BETTER
+DTO
What specific behaviors constitute “+DTO”?
Labile
Describe the different mood states, how quickly they
alternate, whether there are triggers for the alternations,
etc.
Sullen
“When greeted the patient stared intently back at me.
When asked how he felt, he said, ‘I hate it here.’”
Sexually Inappropriate
The patient began masturbating in the dayroom.
Disruptive
She frequently interrupted the group leader and other
participants, shouting her thoughts and reactions.
Suicidal or +SI
Ideation? Passive or Active? Intent? Specific Plan?
Means? Opportunity? Timing?
+DTS
What specific behaviors constitute “+DTS”?
+SIB
Describe the specific types of self-injurious behavior. What
were the medical consequences?
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THE LANGUAGE WE USE
DON’T WRITE THIS
THIS WOULD BE BETTER
Despondent
The patient said, “I feel there is no hope for me. There is
nothing I can do to change my life.”
Psychotic
Appears preoccupied with listening to voices. Frequently
shouts in response to what she hears.
Disorganized
In what specific ways is the patient being “disorganized”?
Example: “Patient smeared feces on the walls of his
bathroom.”
+CAH
What are the voices commanding him to do? Is he able to
resist obeying the commands?
Poor ADLs
Refuses to brush teeth. Has not showered X 2 days.
Describe reasons for behaviors. E.g., are poor ADLS
secondary to skill deficits, delusional beliefs, social
phobia?
Paranoid
Describe the specific behaviors/statements which cause
the writer to describe the patient as “paranoid.”
Regressed
“Patient refused to put on clothing, and continued to sit,
rocking back and forth, in the corner of his room.”
15
THE LANGUAGE WE USE
DON’T SAY THIS
THIS WOULD BE BETTER
Unpredictable
In what specific ways has the patient exhibited
“unpredictable” behavior? E.g., “The patient walked
up to the counter at the nursing station, and shoved
the computer onto the floor.”
+Poor Coping Skills
Describe both the specific behaviors which lead to
the inference that there are “poor coping skills,” as
well as the circumstances in which these deficits
have been observed.
+GD
What observable behaviors constitute “+GD”?
Simply being unable to formulate and/or execute a
plan for self-care does not constitute being gravely
disabled.
Blowing Up
What exactly did the patient do? For example, “He
overturned the medication cart and punched a
mental health worker in the mouth with a closed
fist.”
16
MEDICAL NECESSITY CRITERIA FOR ADMISSION-DIAGNOSIS
• There must be an included diagnosis. Here is a list of the
families of diagnoses which are covered for inpatient
services:
• (A) Pervasive Developmental Disorders (including Autistic
Disorder)
• (B) Disruptive Behavior and Attention Deficit Disorders
• (C) Feeding and Eating Disorders of Infancy or Early
Childhood
• (D) Tic Disorders
• (E) Elimination Disorders
• (F) Other Disorders of Infancy, Childhood, or Adolescence
17
MEDICAL NECESSITY CRITERIA FOR ADMISSION-DIAGNOSIS
• (G) Cognitive Disorders (only Vascular Dementia with Delusions or
•
(H)
•
•
•
•
•
•
•
•
•
•
(I)
(J)
(K)
(L)
(M)
(N)
(O)
(P)
(Q)
(R)
Depressed Mood)
Substance-Induced Disorders (only with Psychotic, Mood
or Anxiety Disorder)
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Dissociative Disorders
Eating Disorders
Intermittent Explosive Disorder
Pyromania
Adjustment Disorders
Personality Disorders (including Antisocial Personality Disorder)
18
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
•
The diagnosis used for audit purposes is the DIAGNOSIS ON
THE DISCHARGE SUMMARY
•
If the admitting and discharge diagnoses are different, the
medical record should include:
 The date on which the change was made
 A description of the clinical information which led to the
change. “Clinical information” may include behavioral
observation, interview findings, psychometric test data, laboratory
studies, imaging studies, responses to treatment, newly received
information about the patient’s medical/psychiatric/psychological
history, and so forth. This is especially important when a
diagnosis changes from a covered to a non-covered one, or
from a non-covered to a covered one.
19
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
• Type 1 Example (Excluded to Included):
– Admitting Diagnosis: Dementia of the
Alzheimer’s Type
– Discharge Diagnosis: Psychotic Disorder NOS
– Medical record should include:
• Date on which the diagnosis was changed
• Clinical data which led to the change. In this case, for
example, the clinical data may have been the results of
an MRI which revealed no diffuse cortical atrophy or
other pathological findings.
20
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
•
Type 2 Example (Included to Excluded):
– Admitting Diagnosis: Psychotic Disorder NOS
– Discharge Diagnosis: Dementia of the Alzheimer’s Type
– Medical record should include:
• Date on which the diagnosis was changed
• Clinical data which led to the change. In this case, for
example, the clinical data may have been one or more of the
following:
– The results of an MRI which revealed diffuse cortical
atrophy or other pathological findings
– Behavioral observation that the patient had difficulty
finding his room, even after several days in the hospital
– No recognition of the attending psychiatrist and other
medical personnel with whom he worked on a daily basis
21
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
In the Type 2 Example on Slide 17, the day on which the hospital
stay would have become non-reimbursable would have been the
day on which the MRI results became available to the patient’s
psychiatrist or psychologist.
In the Type 2 case, the medical necessity determination hinges
on the answer to the following question: “When should a
reasonably astute clinician have become aware that the correct
diagnosis was a non-covered one?”.
22
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
• The way in which diagnoses are written is very
important:
– Diagnoses which are followed by such
words/phrases as “By History” or “Versus
Diagnosis XXX,” or which are preceded by words
such as “Provisional,” “Preliminary,” “Working,” or
“Consider” do not meet medical necessity
criteria.
23
GUIDANCE AND RECOMMENDATIONS-DIAGNOSIS
– A “stand alone” Rule Out Diagnosis does not
meet medical necessity criteria.
– Here is an actual example of what was written as
a “Discharge Diagnosis”: Mood Disorder NOS,
Rule Out Substance-Induced Mood Disorder,
Rule Out Bipolar Disorder , Anxiety Disorder
NOS, Rule Out Obsessive—Compulsive
Disorder, Rule Out Panic Disorder with
Agoraphobia, Rule Out Social Anxiety Disorder,
Rule Out Generalized Anxiety Disorder, Rule Out
Methamphetamine Abuse
24
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
The example on Slide 24 illustrates two important points:
• Eliminate competing diagnoses wherever possible. In this
case, a urine drug screen and a carefully taken history could
have eliminated or established Substance-Induced Mood
Disorder and Methamphetamine Abuse.
• A thorough diagnostic interview, including a comprehensive
mental status examination, should have made it possible to
eliminate one or more of the following:
–
–
–
–
–
Anxiety Disorder NOS
Obsessive-Compulsive Disorder
Panic Disorder with Agoraphobia
Social Anxiety Disorder
Generalized Anxiety Disorder
25
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
• Diagnoses must be supported by the symptoms and behaviors
documented in the assessment.
• Here is an example of diagnoses which were not supported:
• A 45-year-old single female patient reported the onset of
depressed mood six months prior to admission. Three months
prior to admission the patient began consuming large amounts
of alcohol daily. Mental status examination indicated patient’s
memory was “intact” for immediate and recent memory.
– Alcohol-Induced Mood Disorder
– Korsakoff’s Syndrome
26
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
Here is a second example of a diagnosis in need of
clarification:
Admitting Diagnosis:
• Psychotic Disorder NOS, Rule Out Methamphetamine-Induced
Psychotic Disorder
Laboratory Findings on Hospital Day #1:
• Urine Drug Screen Positive for Methamphetamine
Discharge Diagnosis:
• Psychotic Disorder NOS
27
GUIDANCE AND RECOMMENDATIONS-DIAGNOSIS
Implications of Failure to Assign Correct Diagnosis:
• Patient received no inpatient substance use disorder
counseling
• Discharge planning did not center around dual
diagnosis treatment facilities
• The aftercare plan did not include substance use
disorder services
28
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
The following diagnoses/diagnostic groups are among those
which do NOT qualify for Medi-Cal reimbursement for acute
psychiatric inpatient hospital services:
a.
b.
c.
d.
e.
f.
Mental Retardation
Learning Disorders
Motor Skills Disorder
Communication Disorders
Delirium
Dementia (except Vascular Dementia with Delusions or
Depressed Mood)
g. Amnestic Disorders
h. Cognitive Disorder NOS
29
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
i.
Mental Disorders Due to a General Medical
Condition
j. Substance-Induced Disorders (except SubstanceInduced Psychotic, Mood or Anxiety Disorder)
k. Factitious Disorders
l. Sexual and Gender Identity Disorders
m. Sleep Disorders
n. Impulse Control Disorders Not Elsewhere Classified
(except Intermittent Explosive Disorder and
Pyromania)
o. Other Conditions That May Be a Focus of Clinical
Attention (V Codes)
30
GUIDANCE & RECOMMENDATIONS—DIAGNOSIS
• Diagnoses—especially the one which is used to
establish medical necessity—must be clearly and
legibly written or typed on the Discharge Summary.
• Diagnoses must be written out and should
preferably be accompanied by the appropriate ICD
code. Acronyms (e.g., PDNOS) are NOT
acceptable.
31
GUIDANCE AND RECOMMENDATIONS-DIAGNOSIS
• A beneficiary may have both a covered and a noncovered diagnosis. However, a qualifying
impairment resulting from the covered diagnosis
must be the primary focus of the treatment
provided.
32
FREQUENTLY ASKED QUESTIONS: ADMISSION
1. What determines the actual date and time of admission?
ANSWER: Admission is timed from the moment when the
beneficiary is physically brought onto the inpatient unit and
begins to receive care, which is usually documented in a
nursing progress note or assessment. For purposes of MediCal reimbursement, the admission is NOT considered to have
occurred on the date and ate the time of the physician’s
admitting order.
2. Is Autistic Disorder a covered diagnosis for inpatient services?
ANSWER: Yes, it is covered for inpatient services but not for
outpatient services.
33
FREQUENTLY ASKED QUESTIONS: ADMISSION
3. What about Antisocial Personality Disorder?
ANSWER: Yes, it is covered for inpatient services but not for
outpatient services.
4. Is Impulse Control Disorder NOS covered for inpatient
services?
ANSWER: It is not covered for inpatient services, but it is
covered for outpatient services.
34
IMPROVING INPATIENT DOCUMENTATION
REASONS FOR RECOUPMENT—INPATIENT HOSPITAL
SERVICES
Admission—Reason #22
• Documentation does not establish that the beneficiary had an
included diagnosis.
• Documentation does not establish that the beneficiary could not
have been safely treated at a lower level of care, except that a
beneficiary who can be safely treated with crisis residential
treatment services or psychiatric health facility services shall be
considered to have met this criterion.
35
IMPROVING INPATIENT DOCUMENTATION
• Documentation does not establish that the beneficiary, as a
result of an included diagnosis, required admission to an
acute psychiatric inpatient hospital for one of the following
reasons:
– Presence of symptoms or behaviors that represent a
current danger to self or others, or significant property
destruction
– Presence of symptoms or behaviors that prevent the
beneficiary from providing for, or utilizing, food, clothing or
shelter
36
IMPROVING INPATIENT DOCUMENTATION
– Presence of symptoms or behaviors that present a
severe risk to the beneficiary’s physical health
– Presence of symptoms or behaviors that represent a
recent, significant deterioration in ability to function
– Presence of symptoms or behaviors that require
further psychiatric evaluation, medication treatment,
or other treatment that could reasonably be provided
only if the patient were hospitalized
37
MEDICAL NECESSITY CRITERIA—LEVEL OF CARE
MEDICAL NECESSITY CRITERIA—LEVEL OF CARE
REQUIREMENT
• Section 1820.205(a)(2)(A) of CCR Title 9 states that in
order to meet medical necessity criteria for admission to
an acute psychiatric inpatient hospital, documentation
must establish that the beneficiary cannot be safely
treated at a lower level of care, except that a beneficiary
who can be safely treated with crisis residential treatment
services or psychiatric health facility services for an
acute psychiatric episode shall be considered to have
met this criterion.
38
MEDICAL NECESSITY CRITERIA—LEVEL OF CARE
• This criterion is based upon Sections 5325.1 and
5325.1(a) of the Welfare and Institutions Code, which
state:
– It is the intent of the Legislature that persons with
mental illness shall have rights including, but not
limited to, the following:
– (a) A right to treatment services which promote the
potential of the person to function independently.
Treatment should be provided in ways that are least
restrictive of the personal liberty of the individual.
39
MEDICAL NECESSITY CRITERIA—LEVEL OF CARE
In making level of care assessments and determinations, it is
essential to understand not only the patient’s treatment needs
but the range of services available at the various levels of care
as well as the levels of tolerance for certain types of behavior.
Here are some examples:
– The most common types of step-down facilities are crisis
residential treatment facilities and adult residential
treatment facilities. These facilities are not locked facilities,
so the patient’s ability to be safely treated in an open
setting needs to be determined.
– Oral PRN medication is available at crisis and adult
residential treatment facilities, but intramuscular PRN
medication is generally not.
40
MEDICAL NECESSITY CRITERIA—LEVEL OF CARE
– Residential treatment facilities do provide limited
prompting and assistance with activities of daily
living, but they are not able to handle the needs
of total care patients.
– Residential treatment facilities are not able to
accept patients whose behavior is grossly
disorganized or disruptive of the treatment milieu
(e.g., fecal smearing, refusal to remain clothed,
sexual aggression toward others, prolonged
screaming or yelling).
41
IMPROVING INPATIENT DOCUMENTATION
Documentation Example:
Patient went AWOL from her residential placement after
being “influenced by a friend.” The patient was
apprehended by police after she ran into traffic. She
“reported SI if she had to return to her former placement.”
Mental Status Examination: Sixteen-year-old Hispanic
female in no acute distress. Fair eye contact. Cooperative
with interview, answers questions appropriately but says “I
don’t know” to many questions. Mood: Depressed.
Suicidal Ideation: Yes, passive. Suicidal Intent: Yes, if
she has to return to her former placement. Suicidal Plan:
Denies active plan at this time.
42
IMPROVING INPATIENT DOCUMENTATION
Hospital Plan: Patent is appropriate for inpatient level
of care for close monitoring for safety, continued
adjustment in medications to target depression, and
for coordination of outpatient care for continued
control of symptoms after discharge.
Could this patient have been evaluated and treated at
a lower level of care?
43
MEDICAL NECESSITY CRITERIA—INDICATORS
FOR ADMISSION
• The impairment criteria for admission to an acute
psychiatric inpatient hospital are provided in CCR Title 9
Sections 1820.205(a)(2)(B)1.a through
1820.205(a)(2)(B)1.d. and 1820.205(a)(2)(B)2.a. through
1820.205(a)(2)(B)2.c. Here are the criteria:
– Presence of symptoms or behaviors that represent a
current danger to self or others, or of significant
property destruction
– Presence of symptoms or behaviors that prevent the
beneficiary from providing for, or utilizing, food,
clothing or shelter
– Presence of symptoms or behaviors that present a
severe risk to the beneficiary’s physical health
44
MEDICAL NECESSITY CRITERIA—INDICATORS
FOR ADMISSION
– Presence of symptoms or behaviors that represent a
recent, significant deterioration in ability to function
– Need for psychiatric evaluation, medication treatment,
or other treatment which can reasonably be provided
only if the beneficiary is in a psychiatric inpatient
hospital
 REMEMBER: The qualifying impairment must be
the direct result of the included diagnosis.
45
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
GENERAL POINT:
In those hospitals where patients are admitted from a crisis
stabilization unit (CSU) or a psychiatric emergency service
(PES), it is imperative that decisions regarding admission be
based upon the beneficiary’s clinical condition just prior to
admission—and not upon the behaviors and symptoms which
the beneficiary was exhibiting at the time of entry into the CSU or
PES.
46
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
1. CURRENT Danger to Self (DTS), Danger to Others (DTO), or
Danger to Property (DTP). In order to meet one of these
three impairment criteria, there must be documentation of
suicidal, homicidal or property destruction ideation, together
with either documented intent or a specific plan.
(a) If the beneficiary is experiencing command auditory
hallucinations to harm self or others, or to destroy
property, this fact should be documented together with
an assessment of the beneficiary’s ability to resist
obeying the commands. In the absence of such
documented assessment, the presence of command
auditory hallucinations alone does not establish that the
beneficiary is a DTS, DTO or DTP.
47
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
(b) It sometimes occurs that a beneficiary expresses
suicidal/homicidal/property destruction ideation, intent
and/or specific plan in a way which is purely
conditional—e.g., “I feel safe here, but if I were
discharged, I would kill myself by overdosing on my
medication.” In such cases, in order to establish medical
necessity for admission (or for continued stay services),
there must be a documented assessment of how the
beneficiary would react to/feel about being discharged to
a residential treatment facility where s/he would have
24-hour access to staff.
48
MEDICAL NECESSITY CRITERIA—INDICATORS
FOR ADMISSION/IMPAIRMENT CRITERIA
Many times beneficiaries make these conditional
statements because :
1) they fear being discharged to a place where they would
not have adequate support and professional attention
2) they do not have access to food and shelter or the
means to purchase them.
If the assessment reveals that the beneficiary would feel
safe in a residential treatment facility, then admission (or
continued stay services) would not be appropriate.
49
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
(c) Although documentation of general risk factors
does not establish medical necessity, such
documentation may constitute supplementary
information which is useful in making treatment and
discharge planning decisions.
50
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
2. Beneficiary is unable to provide for or utilize food,
clothing or shelter.
(a) The correct standard to apply when evaluating for
this criterion is whether the beneficiary is able to utilize
(rather than formulate / carry out a plan for obtaining)
the food, clothing and shelter which is provided. The
reason this is the correct standard is that in the
step-down levels of care to which the beneficiary
could be diverted or discharged, food, clothing and
shelter are provided.
51
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
(b) Some of the symptoms/behaviors which meet this
impairment criterion are: (1) Refusing to eat and/or
take liquids to an extent which jeopardizes the
beneficiary’s health status; (2) Refusing to remain
clothed; (3) Engaging in sexual behavior in public
areas; and (4) Behaving in so grossly disorganized a
manner as to be unmanageable at a lower level of
care (e.g., smearing feces, urinating in public areas).
52
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
3. Beneficiary has symptoms/behaviors that present a
severe risk to his/her health.
(a) The essential element is that the symptoms /
behaviors which present a severe risk to the
beneficiary’s physical health must be a direct result
of the covered diagnosis. In order to qualify, the
behaviors creating the risk cannot be the result
of a deliberate, rational decision reached by the
beneficiary.
53
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
(b) The most frequently encountered example of
this type of impairment would be refusal to eat
secondary to Anorexia Nervosa. A less common,
example would be refusal to eat secondary to
delusional beliefs (e.g., that food is poisoned or that
spiritual salvation can only be achieved by depriving
the physical body of sustenance).
(c) A patient’s saying, “I am going to drink myself to
death” does not meet this criterion because the
proclaimed behavior does not represent a current
or even short-range danger to self.
54
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
4. Beneficiary has symptoms/behaviors that represent a recent,
significant deterioration in ability to function.
(a) The level of care criterion still applies here: Even if there
is a “recent, significant deterioration in ability to function,”
when the beneficiary could be evaluated and treated at a
lower level of care admission (and continued stay
services) may not be reimbursable.
(b) Documentation should include a description of the
patient’s previous level of functioning as well as an
explanation of why the patient could not be safely and
effectively treated at a lower level of care.
55
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
(c) If there is a medical (as opposed to
psychiatric) basis for the recent, significant
deterioration in ability to function, the hospital stay
would not be reimbursable.
56
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
5. Beneficiary requires further psychiatric evaluation.
The level of care criterion applies here:
(a) If the evaluation which the beneficiary requires could be
provided at a lower level of care, the admission is not
reimbursable.
(b) If the justification for the admission is based upon
convenience to the beneficiary (or the staff), the
admission is not reimbursable.
57
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
6. Beneficiary requires medication treatment.
As before, the level of care criterion applies here:
(a) If the medication treatment or medication adjustment
which the beneficiary requires could be performed at a
lower level of care (such as an outpatient clinic), then the
admission is not reimbursable.
58
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
If, however, a patient has experienced a life
threatening reaction to a medication in the past (e.g.,
agranulocytosis or neuroleptic malignant syndrome),
and there is a clinically compelling reason why the
patient needs to be restarted on the same medication,
this could constitute a valid reason for restarting the
medication in an inpatient hospital setting.
59
GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR
ADMISSION/IMPAIRMENT CRITERIA
7. Beneficiary requires other treatment that can reasonably be
provided only if the patient is hospitalized.
(a) If the beneficiary does not meet any of the preceding
impairment criteria, it is unlikely that s/he will meet this one
because nearly all treatments, including electroconvulsive
treatment, may be safely provided on an outpatient basis.
(b) Convenience of the staff or beneficiary does not satisfy
this criterion.
60
FOCUS OF TREATMENT REQUIREMENT
The primary focus of the treatment must be to address the
qualifying indicator which establishes medical necessity for
admission.
Example: If a patient is admitted with a diagnosis of AlcoholInduced Mood Disorder and is determined to be a Danger to
Self, the focus of the treatment must be to address the dysthymia
and to reduce the impairments which constitute the “Danger to
Self”—e.g., suicidal ideation and either intent or a specific plan.
The primary (or only) focus of the treatment may NOT be on
preventing withdrawal symptoms—although it may be a
secondary focus of treatment.
61
EFFICACY REQUIREMENT
The efficacy requirement means that the treatment planned for
and provided to the beneficiary must have a reasonable
likelihood of reducing the impairment resulting from the qualifying
indicator for admission. The following are examples of
treatments which would not meet the efficacy requirement:
• Occupational therapy focusing on arts and crafts and the
development of fine motor skills as the only psychosocial
treatment for a patient admitted with AttentionDeficit/Hyperactivity Disorder.
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EFFICACY REQUIREMENT
• Antipsychotic medication prescribed as the primary
treatment for a patient with Intermittent Explosive
Disorder in the absence of hallucinations, delusions
or thought disorder.
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IMPROVING INPATIENT DOCUMENTATION
FREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION
1. Is it permissible to use forms which consist entirely of check boxes
for staff to fill in?
ANSWER: No. If check boxes are used, there must be some
narrative statement by the physician/nurse which confirms and
elaborates upon the checked box(es).
Many times the labels attached to check boxes are not behaviorally
specific and do not communicate any precise meaning. For example, a
check box labeled “Suicidal” does not convey specific information. If the
box is checked, the reader does not know which of the following
elements is present: ideation, intent, plan, means, opportunity.
Similarly, a check box labeled “DTO” does not communicate the way(s)
in which the patient is a danger to others.
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IMPROVING INPATIENT DOCUMENTATION
2. Does there have to be a physician’s note for every claimed
hospital day?
ANSWER: Although this is a highly desirable practice, MediCal regulations do not require that there be a physician’s
note for each hospital day (or, for that matter, any physician’s
notes). What is required is that there be documentation
which establishes medical necessity for each claimed day.
65
MEDICAL NECESSITY CRITERIA—INDICATIONS
FOR CONTINUED STAY SERVICES
The impairment criteria for continued stay services in an acute
psychiatric inpatient hospital are in CCR Title 9 Sections
1820.205(b)(1) through 1820.205(b)(4):
– Presence of symptoms or behaviors that represent a
current danger to self or others, or of significant property
damage
– Presence of symptoms or behaviors that prevent the
beneficiary from providing for, or utilizing, food, clothing or
shelter
– Presence of symptoms or behaviors that present a severe
risk to the beneficiary’s physical health.
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IMPROVING INPATIENT DOCUMENTATION
– Presence of symptoms or behaviors that represent a recent,
significant deterioration in ability to function
– Need for further evaluation, medication treatment, or other
treatment that can reasonably be provided only if the beneficiary
is in a psychiatric inpatient hospital
– Presence of one of the following:
o A serious adverse reaction to medications
o Procedures or therapies requiring continued hospitalization
o The presence of new indications that meet medical necessity
criteria
o The need for continued medical evaluation
o Treatment that can only be provided if the beneficiary remains
in a hospital
67
GUIDANCE AND RECOMMENDATIONS—
CONTINUED STAY SERVICES
1.
Documentation on continued stay service days should
reflect symptoms and behaviors exhibited on that
day and not on previous days, including the day of
admission or days on which the patient was in a CSU
or PES.
2.
Documentation should reflect the beneficiary’s actual
progress. Symptomatic improvement is almost always
gradual rather than sudden.
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IMPROVING INPATIENT DOCUMENTATION
3. When a beneficiary is admitted following a high lethality
suicide attempt, a serious attempt to harm another, or a
serious attempt to destroy property, it is understandable that
the hospital professional staff may be reluctant to discharge
the beneficiary as soon as the denial of symptoms has
begun. In these cases, it is appropriate to grant one or more
stabilization days during which the staff may continue to
assess the beneficiary in a protected setting and determine
whether this improvement is genuine or only apparent.
Stabilization days should be used only following a high
lethality event and then very cautiously.
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IMPROVING INPATIENT DOCUMENTATION
4.
When documentation from different disciplines
shows a pattern of inconsistency or
contradiction, the credibility of the entire medical
record suffers. In general, greater weight is
accorded documentation which is more
behaviorally specific.
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IMPROVING INPATIENT DOCUMENTATION
Documentation Example:
Patient was observed to be isolative, withdrawn,
pacing most of the time in the hallways. Patient was
observed talking to himself and seeing people.
Patient was agreeable with starting psychotropic
medication and he signed the consent for medication.
What do you think of this note?
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IMPROVING INPATIENT DOCUMENTATION
Documentation Example:
“Patient is very irritable, guarded, paranoid, labile, intrusive, very
short-tempered, brusque during this interview and becomes
guarded, irritable and demanding during this evaluation. States
he has not been able to sleep in spite of Seroquel, and agrees to
a dosage increase. Agrees to the addition of Depakote for his
mood stabilization. Patient continues to be depressed,
dysphoric, unable to contract for safety. High risk of explosive
and self-destructive behavior; requires inpatient treatment and
stabilization.”
Comments?
72
FREQUENTLY ASKED QUESTIONS
1.
Does a history of previous psychiatric
hospitalizations affect the likelihood that the
beneficiary’s current hospital stay will be MediCal reimbursable?
ANSWER: In general, medical necessity determinations
are based upon an evaluation of the patient’s current
symptoms and behavior. However, if a patient has a
history of multiple hospitalizations resulting from highlethality suicide or homicide attempts, these historical
events may be taken into account indirectly if
circumstances or triggers similar to those which were
associated with previous incidents are present during the
current admission.
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IMPROVING INPATIENT DOCUMENTATION
2.
Do chart notes written by medical students
“count” in making medical necessity
determinations?
ANSWER: Medical necessity determinations should be
based upon documentation written by licensed, registered
or waivered mental health professionals. However,
documentation written by non-licensed individuals (e.g.,
medical students, interns, or, in some cases, residents)
may be used to provide confirmation of information
contained in progress notes written by licensed, registered
or waivered individuals.
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IMPROVING INPATIENT DOCUMENTATION
REASONS FOR RECOUPMENT—INPATIENT HOSPITAL
SERVICES
Continued Stay Services—Reason #23
•
Documentation does not establish the continued presence of an included
diagnosis
•
Documentation does not establish that the beneficiary could not have been
safely treated at a lower level of care, except that a beneficiary who can be
safely treated with crisis residential treatment services or psychiatric health
facility services shall be considered to have met this criterion
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IMPROVING INPATIENT DOCUMENTATION
• Documentation does not establish that, as a result of an included
mental disorder, the beneficiary required continued stay services for
one of the following reasons:
– Presence of symptoms or behaviors that represent a current
danger to self or others, or significant property destruction
– Presence of symptoms or behaviors that prevent the beneficiary
from providing for, or utilizing, food, clothing or shelter
– Presence of symptoms or behaviors that present a severe risk to
the beneficiary’s physical health
– Presence of symptoms or behaviors that represent a recent,
significant deterioration in ability to function
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IMPROVING INPATIENT DOCUMENTATION
– Presence of symptoms or behaviors that require further
psychiatric evaluation, medication treatment, or other treatment
that can reasonably be provided only if the patient is hospitalized
– Presence of a serious adverse reaction to medications,
procedures or therapies requiring continued hospitalization
– Presence of new indications that meet medical necessity criteria
specified for admission
– Presence of symptoms or behaviors that require continued
medical evaluation or treatment that can only be provided if the
beneficiary remains in an acute psychiatric inpatient hospital
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IMPROVING INPATIENT DOCUMENTATION
REQUIREMENTS FOR PLANS OF CARE
The required elements for acute psychiatric inpatient hospital plans of care
are to be found in two different sources:
•
•
The Code of Federal Regulations, Title 42, Section 456.180 and
The contract between DHCS and the MHPs, Exhibit A,
Attachment 1.
These requirements are as follows:
Code of Federal Regulations, Title 42, Section 456.180
(a)
Before admission to a mental hospital or before authorization for
payment the attending physician or staff physician must
establish a written plan of care for each applicant or
beneficiary.
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IMPROVING INPATIENT DOCUMENTATION
(b)
The plan of care must include–
(1)
(2)
(3)
(4)
Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
A description of the functional level of the individual;
Objectives;
Any orders for—
(i)
Medications;
(ii)
Treatments;
(iii)
Restorative and rehabilitative services;
(iv)
Activities;
(v)
Therapies;
(vi)
Social services;
(vii)
Diet; and
(viii)
Special procedures recommended for the
health and safety of the patient;
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IMPROVING INPATIENT DOCUMENTATION
(5) Plans for continuing care, including review and
modification to the plan of care; and
(6) Plans for discharge.
(c) The attending or staff physician and other personnel
involved in the beneficiary’s care must review each
plan of care at least every 90 days.
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IMPROVING INPATIENT DOCUMENTATION
Contract Between DHCS and the MHPs
(1)
The Contractor shall ensure that Client Plans:
(a) Have specific observable and/or quantifiable goals/treatment
objectives related to the beneficiary’s mental health needs and
functional impairments as a result of the mental health diagnosis;
(b) Identify the proposed type(s) of intervention/modality
including a detailed description of the intervention to be
provided;
(c) Have a proposed frequency and duration of intervention(s);
(d) Have interventions that focus and address the identified
functional impairments as a result of the mental disorder;
have interventions that are consistent with the client plan goal;
(e) Be consistent with the qualifying diagnoses;
(f) [Not Applicable to inpatient client plans.]
(g) Include documentation of the beneficiary’s participation in
and agreement with the client plan.
81
GUIDANCE AND RECOMMENDATIONS—PLANS
OF CARE
1.
For audit purposes, the plan of care is considered to consist of
the interdisciplinary (or master) treatment plan PLUS the
physician’s admitting order sheet.
2.
CFR Section 456.180(a) requires that “the attending physician
or staff physician must establish a written plan of care . . .”
The physician indicates his/her establishment of the plan by
signing the plan of care.
3.
The plan of care must be completed for all hospital stays which
are greater than or equal to 72 hours in length.
4.
The client plan may NOT be imbedded in a progress note, but
must be a separate document which is labeled “Client Plan” or
“Master Treatment Plan” or “Interdisciplinary Treatment Plan” or
something similar.
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IMPROVING INPATIENT DOCUMENTATION
FREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION
1.
May the physician’s signature be on a progress note which
refers to the client plan?
ANSWER: No. The physician’s signature establishing the plan
of care must be on the plan itself.
2.
What if there is a signature on the client plan but it is illegible?
ANSWER: If the signature can be verified through a signature
sheet it may be counted.
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IMPROVING INPATIENT DOCUMENTATION
FREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION
3. Is it permissible to use subjective rating scales to quantify patient
status/patient goals? For example, is it permissible to have the patient
rate his/her mood on a scale from 1 to 10?
ANSWER: Yes. Subjective rating scales are permissible. These
scales work best when the endpoints, as well as one or two “anchor
points” between the endpoints of the scale, are defined in specific terms
in collaboration with the patient.
4. Should progress notes refer to the goals described in the plan of care?
ANSWER: Yes. It is important that each progress note address those
patient goals which are within the scope of practice of the person
writing the note.
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IMPROVING INPATIENT DOCUMENTATION
Interdisciplinary Treatment Plan Example
Problem #1:
• DTS AEB pt. wants P.D. to shoot her.
Problem #2:
• Alteration in cardiac output AEB pt. Hx of HTN.
Short-Term Goal #1 for Problem #1:
• Pt. will not be a risk to herself while hospitalized. Intervention: Monitor pt. q
15 min, provide safe environment.
Short-Term Goal #2 for Problem #1:
• Pt. will attend and participate in daily Tx team prior to D/C. Interventions:
Build rapport and develop level of trust on a daily basis.
Comments?
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IMPROVING INPATIENT DOCUMENTATION
Client Plan—Reason #27
The client plan was not signed by a physician.
Other—Reason #28
A hospital day was claimed and paid (1) on which the beneficiary was
not a patient in the hospital, or (2) for the day of discharge, neither of
which is reimbursable.
86
REQUIREMENTS FOR ADMINISTRATIVE DAY
SERVICES
The requirements for administrative day services are located in
two places in Title 9 of the California Code of Regulations:
• Section 1820.220(j)(5) (Point of Authorization)
• Section 1820.230(d)(2) (Utilization Review Committee).
The contents of these two sections are the same. The following
is from Section 1820.230(d)(2):
(2) Requests for MHP payment authorization for administrative
day services shall be approved by the hospital’s Utilization
Review Committee when both of the following conditions
are met:
87
REQUIREMENTS FOR ADMINISTRATIVE DAY
SERVICES
(A) During the hospital stay, a beneficiary previously had met
medical necessity criteria for acute psychiatric inpatient
hospital services;
(B) There is no appropriate, non-acute residential treatment facility
within a reasonable geographic area and the hospital
documents contacts with a minimum of five appropriate, nonacute residential treatment facilities per week for placement of the
beneficiary subject to the following requirements:
(1)
The MHP or its designee can waive the requirement of
five contacts per week if there are fewer than five
appropriate, non-acute residential treatment facilities
available as placement options for the beneficiary. In no
case shall there be less than one contact per week.
88
REQUIREMENTS FOR ADMINISTRATIVE DAY
SERVICES
(2)
The lack of placement options at appropriate,
residential treatment facilities and the contacts
made at appropriate treatment facilities shall be
documented to include but not be limited to:
a. The status of the placement option.
b. Date of the contact.
c. Signature of the person making the
contact.
89
GUIDANCE AND RECOMMENDATIONS—
ADMINISTRATIVE DAY SERVICES
“Non-acute residential treatment facilities” means facilities
at which mental health treatment is provided to all
beneficiaries for a significant period of time Monday
through Friday of each week.
1.

If a facility transports beneficiaries to treatment at an offsite location, that facility does not qualify as a
residential treatment facility. Just how many minutes
per day qualify as “a significant period of time” is up to the
MHP.
 Non-augmented or regular board and care facilities
do NOT qualify as “residential treatment facilities.”
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GUIDANCE AND RECOMMENDATIONSADMINISTRATIVE DAY SERVICES
 Augmented board and care facilities may qualify,
depending upon the type, duration and frequency of
services provided to beneficiaries.
 Case management does not count as
“treatment” for purposes of this definition.
 For children and adolescents, the definition of “nonacute residential treatment facility” usually consists
of a designation by the MHP in its Implementation
Plan of certain RCL levels.
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GUIDANCE AND RECOMMENDATIONS—
ADMINISTRATIVE DAY SERVICES
2.
Waivers of the five-contact-per-week requirement by
Point of Authorization/MHP staff must be in writing, and
should be made part of the Utilization Review file for
each beneficiary to whom the waiver applies.

There must be documentation which meets all
administrative day requirements on the first day for
which administrative day services reimbursement is
granted. This date is designated as Day #1.

Weeks should then be counted off as follows: Week #1
= Day #1 through Day #7; Week #2 = Day #8 through
Day #14; Week #3 = Day #15 through Day #21, and so
on.
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GUIDANCE AND RECOMMENDATIONS—
ADMINISTRATIVE DAY SERVICES

For each week, the number of contacts which meet all
requirements should be summed and multiplied by 1.4.
This product (# of days meeting requirements X 1.4)
yields the number of reimbursable days in that
particular week.
 If acute days are interspersed between administrative
days, the marking off of weeks should begin when
administrative days resume.
 The rule of multiplying the number of qualifying contacts
X 1.4 days works for “weeks” with fewer than seven days.
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GUIDANCE AND RECOMMENDATIONS—
ADMINISTRATIVE DAY SERVICES
3. “The status of the placement option” means a definite
status—e.g., “patient accepted, bed will be available on
September 2, 2010,” “patient accepted, is second on
waiting list,” “patient rejected for admission.”

The following are not considered to constitute a “status of
the placement option”: “Packet FAXed,” “Left message,”
“Spoke with _________, who said that packet is under
review,” “Need documentation of TB skin test,” “Need
more recent laboratory values,” “Patient may be
acceptable; packet still under review.”
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GUIDANCE AND RECOMMENDATIONS—
ADMINISTRATIVE DAY SERVICES
When a patient who has been on administrative days is
discharged home, or back to the facility from which
he/she was admitted, the medical record must be
examined to determine whether this abrupt change in the
discharge plan was foreseeable.
5.

In other words, if the hospital was, in good faith,
searching for a placement to which it fully intended to
discharge the patient, but unforeseeable events outside of
the hospital’s control operated to abort its discharge plan,
then credit may be given for those administrative days
which meet Title 9 criteria.
95
FREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION
1.
May administrative days be claimed when the hospital is
waiting for an LPS conservatorship to be approved but is
not actually contacting potential placements?
ANSWER: No.
2.
If the first contact with a potential placement is
documented on administrative day #3, may that contact
be “counted” for administrative days #1 and #2?
ANSWER: No. There must be at least one documented
placement contact which meets all requirements on the
first administrative day for which reimbursement is
approved.
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IMPROVING INPATIENT DOCUMENTATION
3. If a hospital deals with corporate entities which control multiple
non-acute residential treatment facilities, does one call to a
corporate entity which controls five facilities count as the five
contacts for a one-week period?
ANSWER: No. If, for example, there are three corporate
entities which control all of the non-acute residential facilities
within a reasonable geographic area, and those entities
control five, three, and seven facilities, respectively, then the
hospital is expected to contact all three. Although calling one
corporate entity may reach five or more potential placements, the
hospital in making that one call has not exceeded the required
five contacts per week. There is no acceptable justification for
not calling the other two corporate entities.
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IMPROVING INPATIENT DOCUMENTATION
Administrative Day Services—Reason #24
Documentation does not establish that the beneficiary previously
met medical necessity for acute psychiatric inpatient hospital
services during the current hospital stay.
Administrative Day Services—Reason #25
Documentation does not establish that there were contacts with a
minimum of five (5) appropriate, non-acute residential treatment
facilities per week for placement of the beneficiary which included
(1) the status of the placement option, (2) the date of the contact,
and (3) the signature of the person making the contact.
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IMPROVING INPATIENT DOCUMENTATION
Two Reminders Regarding Interpreter Services
1. When a patient whose preferred language is other than
English is admitted to an inpatient unit, the hospital must
make interpreter services available to the patient so that he
or she can communicate with treatment staff. These
interpreter services may be provided by staff who are fluent
in the patient’s preferred language, or by an interpreter
service via telephone. Family members should not be
asked to act as interpreters unless the patient
specifically requests this and refuses other options for
interpreter services.
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IMPROVING INPATIENT DOCUMENTATION
2. Patients whose preferred language is other than English
must also be provided with interpreter services during
assessments, treatment planning meetings, treatment team
meetings, and individual and group treatment sessions.
These interpreter services may be provided by staff fluent in
the patient’s preferred language or by interpreters who are
physically present on the inpatient unit. The fact that a
patient’s preferred language is other than English should not
prevent him or her from receiving the full benefit of the
treatment program which is offered to English speaking
patients.
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IMPROVING INPATIENT DOCUMENTATION
EXAMPLES OF DOCUMENTATION DEFICIENCIES AND
SOME RECOMMENDATIONS
The most frequent reasons for disallowance—both for admission
and for continued stay services—are failure to establish that (1)
the patient could not have been treated at a lower level of care,
and (2) the patient met impairment criteria for admission or
continued stay services. Here are some examples, together with
additional suggestions:
a. The symptoms/behaviors for the day of admission
are actually those which characterized the
beneficiary during his/her stay in the CSU
or PES, rather than upon the actual day of admission.
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b. The symptoms/behaviors for continued stay service days
are actually those which were observed on the day
of admission but which were repeated in documentation for
subsequent hospital days by staff from one discipline, even
though the documentation by other disciplines contradicts it.
c. Documentation does not contain elements required to
establish impairment. For example:
i. Symptom description is limited to “+SI, AH/VH, CAH,
disorganized, unpredictable.” There is no clarification as to
whether the suicidal ideation is active or passive, no description
of the content of the ideation, no documented assessment of
suicidal intent, no assessment as to the presence of a plan, no
discussion of the availability of means/opportunity, and no
assessment of the nature of the command auditory
hallucinations or the patients ability to resist obeying them.
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IMPROVING INPATIENT DOCUMENTATION
ii. The documentation states that the patient is “at risk”
for self-harm, harm to others, etc., but no basis for
this type of assertion is provided.
iii. The patient is said to be “GD, unable to
formulate/carry out a plan for self-care.” As noted
previously, the correct standard to apply in
determining grave disability is whether the patient is
able to avail himself/herself of the food, clothing and
shelter which could be provided at a lower level of
care.
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IMPROVING INPATIENT DOCUMENTATION
iv. No assessment of vegetative signs.
v. Inadequate assessment of characteristics of sleep,
including sleep pattern. For example, the presence of
early morning awakening might suggest the presence of
melancholia, which in turn might affect the choice of an
antidepressant.
vi. No assessment of stressors antecedent to symptom
onset.
vii. No assessment of resource limitations which might
exacerbate the impact of stressors on the severity of
depression.
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IMPROVING INPATIENT DOCUMENTATION
d. There is little or no exploration of the patient’s symptomatology. For
example, with beneficiaries complaining of depression, which is the
most frequent cause for hospitalization, one or more of the following is
often observed:
i.
No assessment of the quality of the beneficiary’s affective state:
Is the depression experienced as a poignant feeling, or is there a
generalized flattening of emotionality?
ii. No assessment of the patient’s cognitive status. For example, is
there significant cognitive “narrowing,” or either/or thinking. The
presence of cognitive narrowing is an important indicator that
psychotherapy may be indicated (especially cognitive restructuring)
in addition to other treatment modalities.
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IMPROVING INPATIENT DOCUMENTATION
e. There is often no apparent relationship between the beneficiary’s
symptomatology and the choice of psychopharmacological agent. With
increasing frequency there is a tendency for beneficiaries to receive
treatment with drugs from several classes: an antidepressant, an
antipsychotic, an anxiolytic, and a mood stabilizer.
f. There is no systematic assessment and documentation of the
beneficiary’s ability to be managed at a lower level of care. Inpatient
charts frequently state that the “patient cannot be managed at a lower
level of care,” but fail to explain—in behaviorally specific terms—why
this is the case.
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IMPROVING INPATIENT DOCUMENTATION
Treatment Plans
Plans of care frequently exhibit the following deficiencies:
a. Treatment goals focus exclusively on keeping the beneficiary
safe (or keeping him/her from harming others) rather than upon
keeping him/her safe AND treating the biopsychosocial
problems which caused the beneficiary to come to the
hospital in the first place.
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IMPROVING INPATIENT DOCUMENTATION
b.
Treatment goals tend to be “all or nothing.”
 For example, a goal for a “suicidal” beneficiary might be: “Patient
will not engage in self-harming behavior during the hospitalization.”
Or: “Patient will not have any suicidal ideation at the time of
discharge.” An example of a frequently seen goal for a psychotic
patient is, “Patient will not report auditory hallucinations at the time
of discharge.” For most psychotic beneficiaries, this is not a
realistic goal.
 Reducing the frequency and intensity to a tolerable level might be
realistic, however, as would equipping the beneficiary with coping
skills to allow him/her to live with chronic psychotic symptoms.
 Goals must be behaviorally specific and must be quantified. As
mentioned previously, many symptoms can be quantified through
self-report with the aid of a simple scale with clearly defined anchor
points.
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IMPROVING INPATIENT DOCUMENTATION
c. Interventions tend to be standardized rather than customized
for the individual beneficiary. Not only should the interventions
themselves be tailored to the needs and characteristics of a
particular beneficiary, but the manner of approach to the patient
should also be customized and spelled out in the plan of care.
d. Most interventions tend to be milieu-based rather than being
actions which are carried out within the context of a therapeutic
relationship—whether group or individual.
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IMPROVING INPATIENT DOCUMENTATION
One of the most significant deficiencies found frequently in inpatient
charts is the absence of case conceptualization. We will illustrate
this deficiency with a clinical example, and will then demonstrate
hypothetically how the case could have been adequately
conceptualized and treatment planned.
One brief example will illustrate:
• The patient was an 18-year-old male brought to the hospital
after his father interrupted him in the process of attempting to
hang himself from a rafter in the garage. The physician’s notes
focused on the suicide attempt, vaguely described continuing
but fleeting suicidal ideation, “continuing depression” without
additional specification , and the titration of a serotonin reuptake
inhibitor. No psychotherapy was provided during the hospital
stay.
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IMPROVING INPATIENT DOCUMENTATION
• The diagnosis was Mood Disorder NOS.
• The patient was discharged home on the eighth hospital day, with
follow-up by a local mental health clinic.
• Nowhere in the chart was there documentation of any attempt to
understand this young man’s predicament or to develop a
comprehensive conceptualization which would provide an
understanding of his state of mind and the reasons for his
behavior.
• When the case was discussed by DHCS reviewers with hospital
staff they said only, “Well, he was very depressed, he tried to
commit suicide. He came to the hospital, and then he received
medication treatment.”
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IMPROVING INPATIENT DOCUMENTATION
Consider just four possible alternative formulations, each
of which is described very briefly here:
– The patient was experiencing the onset of symptoms
associated with a first schizophrenic episode, and
was terrified of what was happening to him. He felt
desperate and did not know what to do.
– The patient had been sexually molested repeatedly
by an uncle, and had recently begun to have thoughts
of himself molesting a young child himself. These
thoughts were accompanied by sexual arousal.
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– The patient was experiencing Major Depressive
Disorder with Melancholic Features, a condition which
had led his maternal aunt to commit suicide. He had
chosen the anniversary of her suicide as the day on
which to commit the act himself.
– The young man had come to a realization that he was
homosexual, and did not believe there was any hope
of his living a normal, happy, and fulfilling life. Suicide
appeared to him to be his only option.
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We will use the outline of this case to construct, hypothetically,
the elements necessary to meet medical necessity criteria for
inpatient hospital services, as well as to develop a treatment
plan which meets federal, State and contractual requirements.
Diagnosis:
296.23 Major Depressive Disorder, Single
Episode, Severe (Without Psychotic Features),
With Melancholic Features
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Symptoms Supporting the Diagnosis
• Depressed mood by self report (feels “empty,” “flat”), which is
worse in the morning
• Significantly diminished interest in almost all activities
• Marked decrease in reactivity to formerly pleasurable stimuli
• Pronounced psychomotor retardation
• Hypersomnia (sleeps 10-12 hours per day)
• Feels that what is happening to him is his “fault,” that it could
have been avoided had he been “a different sort of person”
• Cognitive “narrowing” which causes him to believe that
death is the only possible “solution” for how he feels
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Antecedents to Depressive Symptoms
• Four weeks prior to the onset of symptoms the patient met an
18-year-old male fellow student in an advanced placement
class, and the two of them began spending time together.
After two weeks the patient began having “feelings as though
I wanted to touch the guy or something.” Over the next two
weeks the patient began to realize that he was emotionally
and physically attracted to his friend. When he came to the
realization that he was gay, he began to feel “afraid.” “I didn’t
know what I would say to my dad—he always criticizes
homosexuals—he says terrible things about them. I felt
embarrassed and really ashamed.”
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Over the next two weeks additional symptoms appeared (the
feeling of emptiness, intense guilt, an overriding sense of not
knowing what to do to “make things right”). The patient began
sleeping during the day as well as at night. Finally, he began to
think of the possibility of killing himself as his only “way out.”
These feelings culminated in his attempt to hang himself in the
family garage.
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The Treatment Plan
Impairment #1: A recent, interrupted suicide attempt by hanging
followed by continuing suicidal ideation without intent or specific
plan. The suicidal ideation is related to (a) Feelings of guilt and
shame related to his newly recognized identity as a gay man;
and (b) Cognitive “narrowing” which causes him to believe that
death is the only possible solution for these feelings of guilt and
shame.
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Goal 1-1: Decrease frequency of suicidal ideation from the
current level of 15-20 times per hour to five or fewer times per
hour. Decrease intensity of suicidal ideation from current
intensity of 7 on a scale from 1 (very easy to ignore) to 10
(impossible to ignore and results in fantasizing about various
specific plans) to 3 or below.
Intervention 1-1: Nursing to assess patient each shift to ensure
that no suicidal intent or specific plan is reported. If either is
reported, notify attending psychologist/psychiatrist immediately
and place patient on line of sight observation. Provide a safe,
supportive environment. Provide opportunity for conversations
with nursing and other staff each shift. Encourage
participation in group treatment. Duration: 7 hospital days.
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Goal 1-2: Reduce level of guilt and shame from an 8 on a scale
from 1 (very mild feelings of guilt/shame which are easily
ignored) to 10 (the most severe ever experienced by the patient)
to a 4 (unpleasant but tolerable level of guilt/shame).
Intervention 1-2: Individual psychotherapy 50 minutes twice per
day with staff psychologist. Focus on providing patient with a
safe place in which to express his feelings about being gay.
Help patient to correct erroneous beliefs/assumptions about
sexual orientation. Assist patient in identifying negative selfstatements and use cognitive restructuring to replace them
with affirmative alternatives. Duration: 7 hospital days.
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Goal 1-3: Reduce “cognitive narrowing” to a point where patient
believes (by self report) that there are positive alternatives to his
sexual orientation other than suicide.
Intervention 1-3: Individual psychotherapy 50 minutes twice per
day with staff psychologist. Focus on assisting patient in
understanding that cognitive narrowing is a symptom of
depression. Provide alternative ways of viewing and
understanding what the patient sees as his current
“predicament.” Reinforce the notion that these symptoms are
transitory and can be modified by psychological and
psychiatric treatment. Duration: 7 hospital days.
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Impairment #2: Depressed mood (feeling “empty,” “flat”).
Goal 2-1: Reduce level of depressed mood from 8 on a scale
from 1 (no depression) to 10 (the worst depression the patient
has ever experienced) to a 4.
Intervention 2-1: Discontinue the fluvoxamine (Luvox)
prescribed by outpatient team: This drug is sedating and will
increase patient’s psychomotor retardation. Start patient on
fluoxetine (Prozac) 20 mg q AM. Duration: 7 hospital days.
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Impairment #3: Hypersomnia.
Goal 3-1: Reduce number of hours slept per day from 10-12 to
8-9.
Intervention 3-1: Monitor number of hours slept each night and
during the day. Encourage participation in recreational therapy.
Encourage participation in group exercise program prior to bed
time. Duration: 10 hospital days.
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Impairment #4: Psychomotor retardation.
Goal 4-1: Patient will report an increase in energy level from the
current rating of 3 on a scale from 0 (no energy at all) to 10 (his
“old, usual, energetic self) to a rating of 6.
Intervention 4-1: Fluoxetine as ordered. Daily weights. Report
any weight increase(s) to psychiatrist. Encourage participation
in recreational and art therapy. Duration: 7 hospital days.
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Discharge Plan
Patient has agreed to discharge to a crisis residential treatment
center, which will allow additional time in which to evaluate
potential out-of-home placements. In view of the father’s
continuing staunch opposition to and disapproval of his
son’s sexual orientation (which he has expressed during
family meetings), discharge home is strongly opposed by
the treatment team.
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Plans for Continuing Care
1. Referral to a gay affirmative psychologist for outpatient
assessment and continued individual psychotherapy.
2. Referral to a gay affirmative psychiatrist for continuation of
fluoxetine treatment.
3. Provide patient with information regarding the local Gay and
Lesbian Community Center for ongoing socialization and
support.
4. Provide patient with information on the local suicide
prevention hot line and related resources.
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5. If patient as well as his mother and father are willing, family
therapy following discharge from the crisis residential
treatment center is recommended. This should be
coordinated by his outpatient psychologist.
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QUESTIONS
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