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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 11201 Contractor Type: MAC A

LCD Information

LCD ID Number: L34570 Status: A-Approved LCD Title: Psychiatric Inpatient Hospitalization Geographic Jurisdiction: South Carolina Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 04/17/2025 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, §1814 (a)(4) states 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. Title XVIII of the Social Security Act, §§1861(a) and (c) defines the terms “spell of illness” and “inpatient psychiatric hospital services.” Title XVIII of the Social Security Act, §1861(f)(1) states the term "psychiatric hospital" means an institution which is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons. Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. 42 CFR §409.62 Lifetime maximum on inpatient psychiatric care 42 CFR §410.32(2)(iii)(A) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 42 CFR §411.4(b) Special conditions for services furnished to individuals in custody of penal authorities 42 CFR §412.23(a) Excluded hospitals: classifications-psychiatric hospitals 42 CFR §412.27 Excluded psychiatric units: Additional requirements 42 CFR §482.61 Condition of participation: Special medical record requirements for psychiatric hospitals CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §10.9 Inpatient Psychiatric Facility Services Certification and Recertification CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §20.3 Psychiatric Hospital, §20.4 Certification of Parts of Institutions as Hospital, §20.5 Part of a Psychiatric Institution as a Psychiatric Hospital, §20.6 General Hospital Facility of Psychiatric Hospital and §20.7 Part of a General Hospital as a Psychiatric Hospital CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 2, §10.1 Background, §20 Admission Requirements, §30 Medical Records Requirements, §30.1 Development of Assessment/Diagnostic Data, §30.2 Psychiatric Evaluation, §30.2.2.1 Principals for Evaluating a Period of Active Treatment, §30.3.1 Individualized Treatment or Diagnostic Plan and §70 Therapeutic Activities CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.4 Electrosleep Therapy (RETIRED), §30.5 Transcendental Meditation CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §130.1 Inpatient Hospital Stays for the Treatment of Alcoholism, §130.3 Chemical Aversion Therapy for the Treatment of Alcoholism, §130.4 Electrical Aversion Therapy for the Treatment of Alcoholism, §130.6 Treatment of Drug Abuse (Chemical Dependency), §130.8 Hemodialysis for Treatment of Schizophrenia and §160.25 Multiple Electroconvulsive Therapy (MECT) Sorry, you need to login or register to view additional sections of this Medicare policy. *