Documentation Requirements for Inpatient Psychiatric Admissions

on Tuesday, 11 December 2018. All News Items | FAQ

Outpatient FAQ December 2018


I understand Medicare Administrative Contractors (MACs) Palmetto GBA (Jurisdictions J and M) and First Coast (JN) are auditing records for MS-DRG 885, Psychoses. What documentation do they expect to see to support payment for these services?


A psychiatric treatment plan developed within the first 3 days of admission that contains

  • a substantiated diagnosis;
  • short-term and long-range measurable, functional, time-framed goals;
  • specific treatment modalities; and
  • responsibilities of each treatment team member.

Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.

Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.

An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.

Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.


Source: Palmetto document – July-September 2018 Part A Inpatient Hospital & Psych Medical Review Top Denial Reasons

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it.

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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