5D700 - No Valid Plan of Treatment Present
The service(s) billed (was/were) not covered because a valid treatment plan established and approved by a physician was not included in the medical records submitted for review as required by Medicare.
To prevent this denial:
In order to avoid unnecessary denials for this reason, when responding to an Additional Documentation Request (ADR), the provider should ensure that the appropriate treatment plan is included and that it is signed by the physician and the mental health professionals contributing to it.
The treatment plan should be developed within the first three (3) days of admission. The focus should be individualized to the patient’s specific strengths and problems as identified in the physician’s psychiatric evaluation, psychosocial and nursing assessments. It should contain a substantiated diagnosis; both short-term and long-range measurable, functional, time-framed goals directed at the individual problems identified as the cause for the patient’s admission; a list of any specific treatment modalities to be utilized in the active treatment of the patient; and a listing of the responsibilities of each member of the treatment team as he/she relates to the plan.
Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.
For more information refer to:
- Code of Federal Regulations, 42 CFR – Section 482.61 (PDF, 142 KB)
- CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Chapter 2, Publication 100-02, Section 30.3 (PDF, 103 KB)
- Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the Palmetto GBA website.
Additional Resource: CERT Checklists.