Mental Health
Residential Treatment Center
To qualify, the
patient’s symptoms or condition must meet the diagnostic criteria for a DSM Axis
I or ICD Diagnosis that is consistent with symptoms and the primary focus of
treatment is residential treatment center (RTC) psychiatric care. All services
must meet the definition of medical necessity in the patient’s plan document.
Severity of
Illness (SI)
The
patient must have all of the following to qualify:
1)
The patient is manifesting symptoms and behaviors which represent a
deterioration from their usual status and include either self-injurious or risk
taking behaviors that risk serious harm and cannot be managed outside of a 24
hour structured setting or other appropriate outpatient setting; AND
2)
The social environment is characterized by temporary stressors or
limitations that would undermine treatment that could potentially be improved
with treatment while the patient is in the residential facility; AND
3)
There should
be a reasonable expectation that the illness, condition or level of functioning
will be stabilized and improved and that a short term, sub-acute residential
treatment service will have a likely benefit on the behaviors/symptoms that
required this level of care, and that the patient will be able to return to
outpatient treatment.
Intensity of
Service (IS)
The
patient must have all of the following to qualify:
1)
Residential treatment takes place in a structured facility-based
setting; AND
2)
Documentation shows that a blood or urine drug screen was done on
admission and during treatment if indicated; AND
3)
Evaluation
by a qualified physician done within 48 hours, and physical exam and lab tests
unless done prior to admission, and eight (8) hour on-site nursing (by a
registered nurse [RN] []) with 24 hour medical availability to manage medical
problems if medical instability identified as a reason for admission to this
level of care; AND
4)
Within 72 hours, a multidisciplinary assessment with an
individualized problem-focused treatment plan completed, addressing psychiatric,
academic, social, medical, family and substance use needs; AND
5)
A psychiatrist is available 24 hours per day, 7 days per week to
assist with crisis intervention and assess and treat medical and psychiatric
issues, and prescribe medications as clinically indicated AND
6)
A Comprehensive Treatment Plan is to be completed within 5 days that
includes:
a) A clear focus on
the issues leading to the admission and on the symptoms which need to improve to
allow treatment to continue at a less restrictive level of care.
b) If this is a
readmission, clarity on what will be done differently during this admission that
will likely lead to improvement that has not been achieved previously.
c) Multidisciplinary
assessments of mental health issues, substance use, medical illness(s),
personality traits, social supports, education, and living situation.
d) The treatment plan
results in interventions utilizing medication management, social work
involvement, individual, group therapies as appropriate.
e) The goal is to
improve symptoms, develop appropriate discharge criteria and a plan that
involves coordination with community resources to allow a smooth transition to a
less restrictive level of care, family integration, and continuation of the
recovery process.
f) All medical and
psychiatric evaluations should include consideration of the possibility of
relevant co-morbid conditions.
g)
This plan should:
·
Be
developed jointly with the individual and family/significant others
·
Establish specific, measurable goals and objectives
·
Include
treatment modalities that are appropriate to the clinical needs of the
individual
·
For
individuals with a history of multiple re-admissions and treatment episodes, the
treatment plan needs to include clear interventions to identify and address the
reasons for previous non-adherence/poor response and clear interventions for the
reduction of future risks
Note: The Treatment Plan is not based on a pre-established programmed plan or
time frames. Medical Necessity and length of stay are to be assessed
individually to ensure appropriate treatment for the appropriate length of time
rather than based on a pre-determined program
7)
Coordination of care with other clinicians, such as the outpatient
psychiatrist, therapist, and the Covered Individual`s PCP, providing treatment
to the patient, and where indicated, clinicians providing treatment to other
family patients, is documented; AND
8)
Treatment would include the following at least once a day and each
lasting 60-90 minutes: community/milieu group therapy, group psychotherapy, and
activity group therapy; AND
9)
Skilled nursing care (RN) available on-site twenty four (24) hours
daily; AND
10)
Individual treatment with a qualified Psychiatrist as frequently as
clinically indicated, but at least once a week including medication management
if indicated; AND
11)
Individual treatment with a licensed behavioral health clinician
at least once a
week; AND
12)
Unless contraindicated, family members participate in development
of the treatment plan, participate in family program and groups and receive
family therapy at least once a week, including in-person family therapy at least
once a month if the provider is not geographically accessible. For children and
adolescents, this includes at least weekly individual family therapy, unless
clinically contraindicated; AND
13)
A discharge plan is completed within one week that includes:
a)
Where the
patient will reside;
b)
Coordination with community resources to facilitate a smooth transition
back to home, family, work or school, and appropriate treatment at a less
restrictive level of care;
c)
Timely and clinically appropriate aftercare appointments, with at least
one appointment within 7 days of discharge;
d)
Prescriptions for any necessary medications, in a quantity sufficient to
bridge any gap between discharge and the first scheduled follow-up psychiatric
appointment AND
14)
The treatment is individualized and not determined by a
programmatic timeframe. It is expected that patients will be prepared to receive
the majority of their treatment in a community setting; AND
15)
For a child or adolescent, the patient’s current living environment does
not provide support for and access to therapeutic services necessary for
recovery; AND
16)
Medication
evaluation and documented rationale if no medication is prescribed.
Continued
Stay Criteria (CS)
The patient
must continue to meet "SI/IS" Criteria and have the following to qualify:
1)
SI criteria are still met and likelihood of benefit and return to
outpatient (OP) treatment is shown by adherence to the treatment plan and
recommendations by the patient and by progress in treatment; if progress is not
occurring than the treatment plan is being amended in a timely and medically
appropriate manner with treatment goals still achievable.
Residential Treatment Detoxification for Substance Use Disorder
To qualify, patient’s
symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD
Substance Dependence diagnosis for residential treatment detoxification. All
services must meet the definition of medical necessity in the patient’s plan
document.
Severity of
Illness (SI)
Nature and
pattern of use of abused substance (s) (including frequency and duration)
predicts the potential for clinically significant withdrawal necessitating
24-hour medical intervention to prevent complications and is not appropriate for
a lower level of care (e.g., alcohol and benzodiazepine withdrawal).
Note:
Withdrawal from stimulants or marijuana alone generally does not require a
medical detoxification and opiate detoxification is generally appropriate for a
lower level of care).
·
Detoxification at this level of care is characterized by its
emphasis on peer and social support rather than intensive medical and nursing
care.
·
Residential Detoxification is only appropriate when substance use
withdrawal symptoms are of moderate severity, such that an intensive medically
monitored inpatient detoxification is not required.
·
Detoxification in Residential Substance Use Disorders Treatment
level of care is NOT appropriate if any of the following circumstances are
present:
a)
The individual does not meet the Medical Necessity criteria for
Residential Substance Use Disorders Treatment.
b)
Objective medical symptoms and/or a history that indicates a high
level of risk for a severe alcohol and/or sedative, hypnotic withdrawal
syndrome, or an opiate withdrawal syndrome that is of such severity that the
individual is not capable of active participation in the residential treatment
program.
c)
An individual
who is suffering from symptoms of a severe co-existing mental or physical
disorder that is of such severity that the individual is not capable of active
participation in the residential treatment program
·
A need for initiation or continuation of detoxification and/or
symptoms associated with withdrawal or post-acute withdrawal should not be the
primary criteria for admission or continued stay at substance residential level
of care.
·
Presence of any of the following may necessitate an acute
hospital level of care:
a)
A
complicating psychiatric illness that requires inpatient treatment; OR
b)
A withdrawal history of delirium tremens, seizures, hallucinations
or acute psychotic reaction secondary to chronic alcohol use and/or
polysubstance drug use; OR
c)
An unstable medical illness that requires daily care by a
consulting physician; OR
d)
Presence of
active withdrawal symptoms that cannot be safely or effectively managed at a
lower level of care.
Intensity of
Service (IS)
The patient must have all of the following to qualify:
1)
Documentation of blood and/or urine drug screen results upon
admission; AND
2)
Multi-disciplinary problem-focused treatment plan that addresses
psychological, social (including living situation and support system), medical,
substance abuse and rehabilitation needs which is re-evaluated and amended in a
timely and medically appropriate manner as indicated; AND
3)
Examination by a qualified physician within 24 hours of admission
and physician visits on a daily basis while in detoxification; AND
4)
24 hours skilled nursing (either an RN or LVN) on site. Note: If
the patient’s medical symptoms require 24-hour nursing care for assessment,
frequent administration of medication, monitoring of vital signs and other
services only provided by a nurse, then acute inpatient detoxification is
required; AND
5)
Medication management of withdrawal symptoms; AND
6)
Discharge planning is initiated on the day of admission and
includes appropriate continuing care plans; AND
7)
Coordination of care with other clinicians, such as the outpatient
psychiatrist, therapist, and the patient’s PCP, providing treatment to the
patient, and where indicated, clinicians providing treatment to other family
members, is documented; AND
8)
Evaluation for medication that may improve the patient`s ability to
remain abstinent; document the rationale if no medication is prescribed; AND
9)
All therapeutic services provided by licensed or certified
professional in accordance with state laws.
Continued
Stay Criteria (CS)
The patient must continue to meet "SI/IS" Criteria and have the
following to qualify:
1)
Progress in treatment is being documented and the patient is not
stable enough to be treated at a lower level of care.
Residential Treatment Center for Substance Abuse Disorder
To qualify, patient’s
symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD
Substance Abuse and/or Dependence diagnosis for residential treatment center
treatment. All services must meet the definition of medical necessity in the
Covered Individual`s plan document.
Severity of
Illness (SI)
The patient must meet criteria 1 or 2, as well as 3 (and 4, for
children and adolescents) to qualify:
1)
Acute psychiatric symptoms that would interfere with:
a)
The patient
maintaining abstinence; AND
b)
Recovery outside of a 24 hour structured setting; AND
c)
Represent a deterioration from their usual status; AND
d)
Include either self-injurious or risk taking behaviors that poses
risk serious harm to the patient or others and cannot be managed outside of a 24
hour structured setting; OR
2)
Acute medical symptoms that would likely interfere with the patient
maintaining abstinence and recovery outside of a 24 hour structured setting;
AND
3)
Evidence of major functional impairment in at least 2 domains
(work/school, ADL, family/interpersonal, physical health); AND
4)
The individual has a documented diagnosis of a moderate-to-severe
substance use disorder, per the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders; AND
5)
For individuals under 18 years, the individual’s family is willing
to commit to active regular treatment participation; AND
6)
As a result of the interventions provided at this level of care,
the symptoms and/or behaviors that led to the admission can be reasonably
expected to show improvement such that the individual will be capable of
returning to the community and to less restrictive levels of care; AND
7)
The individual is able to function with some independence, so as to
be able to participate in structured activities in a group environment; AND
8)
For children and adolescents, the patient’s current living
environment does not provide support for and access to therapeutic services
necessary for recovery.
Intensity of
Service (IS)
The patient must have all of the following to qualify:
1)
Evaluation by a qualified psychiatrist or addictionologist within
48 hours of admission and weekly visits by a qualified psychiatrist if dually
diagnosed and psychiatric symptoms identified as a reason for admission
requiring this level of care; AND
2)
Physical exam and lab tests done within 48 hours if not done prior
to admission, and eight (8) hour on-site nursing (by either an RN or LVN/LPN)
with 24 hour medical availability to manage medical problems if medical
instability identified as a reason for admission requiring this level of care;
AND
3)
Programming provided will be consistent with the patient’s
language, cognitive, speech and/or hearing abilities; AND
4)
Coordination of care with other clinicians, such as the outpatient
psychiatrist, therapist, and the patient’s PCP, providing treatment to the
patient, and where indicated, clinicians providing treatment to other family
members, is documented; AND
5)
Within 48 hours, an individualized, problem-focused treatment plan
is done, based on completion of a detailed personal substance use history,
including identification of consequences of use and identifying individual
relapse triggers as goals; AND
6)
The treatment would include the following at least once per day,
and each lasting 60-90 minutes: community/milieu group therapy, group
psychotherapy and activity group therapy; AND
7)
Family supports identified and contacted within 48 hours and
family/primary support person participation in treatment at least weekly unless
contraindicated. For children and adolescents, this includes at least weekly
individual family therapy, unless clinically contraindicated; AND
8)
Discharge planning completed within one (1) week of admission
including identification of community/family resources, sober supports,
connection or re-establishment of connection to community based recovery
programs and professional aftercare treatment; AND
9)
Drug screens used after all off-grounds activities and whenever
otherwise indicated; AND
10)
All therapeutic services provided by licensed or certified
professionals in accordance with state laws; AND
11)
The treatment is individualized and not determined by a
programmatic timeframe. It is expected that patients will be prepared to receive
the majority of their rehabilitation in a community setting; AND
12)
Evaluation for medication that may improve the patient`s ability to
remain abstinent; document the rationale if no medication is prescribed; AND
13)
All therapeutic services provided by licensed or certified
professional in accordance with state laws.
Relapse should not be the sole criterion for managing an individual in a more
intensive level of care. When appropriate, an evaluation should be performed to
assess the extent of the relapse, its effects on the individual and the family;
the risk of danger/ harm to the individual or others; and the reason for the
relapse.
A
need for initiation or continuation of detoxification and/ or symptoms
associated with withdrawal or post-acute withdrawal should not be the primary
criteria for admission or continued stay at substance use residential level of
care.
Continued
Stay Criteria (CS)
The patient must continue to meet "SI/IS" Criteria and have the
following to qualify:
1)
Progress toward all goals in the treatment plan must be documented
in weekly treatment plan reviews. If progress is not being achieved, then the
treatment plan must be revised with achievable treatment goals; AND
2)
The patient is still participating, following recommendations and
continuing to show a level of motivation such that treatment goals can be
achieved.
Codes Used in This BI:
T2033 Residential Care, per Diem