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LCD ID Number: L33624 Status: A-Approved
LCD Title: Psychiatric Inpatient Hospitalization
Geographic Jurisdiction: Vermont Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
11/14/2019
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following Centers for Medicare and Medicaid Services (CMS) sources:
Title XVIII of the Social Security Act (SSA):
Section 1812(a)(1) Inpatient hospital services defined.
Section 1812(b)(3) Lifetime limit of 190 days for inpatient psychiatric benefit days.
Section 1814(4) Medical Records document that services were furnished while the individual was receiving intensive treatment, admission and related services for a diagnostic study, or equivalent services requirement.
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1835(a) Physician certification as a requirement.
Section 1861(a), 1861(c), and 1861(f) "Spell of illness", "inpatient psychiatric hospital services", "psychiatric hospital", "medical and other health services" defined.
Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Code of Federal Regulations:
42 CFR Section 409.62 describes the lifetime maximum on inpatient psychiatric care.
42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).
42 CFR Section 411.4(a) states that the Medicare Program does not pay for services if the beneficiary has no legal obligation to pay.
42 CFR Section 411.8(a) states that the Medicare Program does not pay for services if the services are paid for directly or indirectly by a governmental entity.
CMS Publications:
CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4:
10 Certification and Recertification by Physicians for Hospital Services - General
10.1 Failure to Certify or Recertify for Hospital Services
10.2 Who May Sign Certification or Recertification
10.4 Inpatient Hospital Services Certification and Recertification
10.5 Selection by Hospital of Format and Method for Obtaining Statement
10.9 Inpatient Psychiatric Facility Hospital Services Certification and Recertification
20.2 Timing for Certification and Recertification for a Beneficiary Admitted Before Entitlement
CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5:
20.3 Psychiatric Hospital
20.4 Certification of Parts of Institutions as a Psychiatric Hospital
20.5 Part of a Psychiatric Institution as a Psychiatric Hospital
20.6 General Hospital Facility of Psychiatric Hospital
20.7 Part of a General Hospital as a Psychiatric Hospital
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2
10 Inpatient Psychiatric Facility Services
10.2 Statutory Requirements
10.3 Affected Medicare Providers
20 Admission Requirements
30 Medical Records Requirements
30.1 Development of Assessment/Diagnostic Data
30.2 Psychiatric Evaluation
30.2.1 Certification and Recertification Requirements
30.2.2.1 Principles for Evaluating a Period of Active Treatment
30.2.3 Services Supervised and Evaluated by a Physician
30.3.1 Individualized Treatment or Diagnostic Plan
30.3.2 Services Expected to Improve the Condition or for Purpose of Diagnosis
30.5 Discharge Planning and Discharge Summary
40 Personnel Requirements
40.1 Director of Inpatient Psychiatric Services; Medical Staff
50 Psychological Services
70 Therapeutic Activities
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 4:
10 Inpatient Psychiatric Benefit Days Reduction
10.1 Patient Status on Day of Entitlement
10.2 Institution's Status in Determining Days Deducted
20 Days of Admission, Discharge, and Leave
30 Reduction for Psychiatric Services in General Hospitals
40 Determining Days Available
50 Inpatient Psychiatric Hospital Services – Lifetime Limitation
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16:
50.3.1Application of Exclusion to State and Local Government Providers
CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:
30.4 Electrosleep Therapy
30.5 Transcendental Meditation
70.1 Consultations with a Beneficiary's Family and Associates
130.1 Inpatient Hospital Stays for the Treatment of Alcoholism
130.3 Chemical Aversion Therapy for Treatment of Alcoholism
130.4 Electrical Aversion Therapy for Treatment of Alcoholism (Electroversion Therapy, Electro-shock Therapy, Noxious Faradic Stimulation)
130.6 Treatment of Drug Abuse (Chemical Dependency)
130.8 Hemodialysis for Treatment of Schizophrenia
160.25 Multiple Electroconvulsive therapy (MECT)
230.4 Diagnosis and Treatment of Impotence
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1:
10.4 Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 3:
30.1 Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part Units
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 29:
230 Where to Appeal and Initial Determinations
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