Postpayment Service-Specific Probe Results for DRG 885: Psychoses for July through September 2021


Palmetto GBA performed service-specific postpayment probe review on DRG 885 — Psychoses. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed July through September, 2021, are presented here.

Cumulative Results 
A total of 512 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 66 of the claims either completely or partially denied. This resulted in an overall claim denial rate of 12.89 percent. The total dollars reviewed were $5,264,935.74, of which $693,028.94 were denied, resulting in a charge denial rate of 13.16 percent. Overall, there was a total of 30 auto-denied claims in the region. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

48.48%

5D800/5H800

Inpatient Psychiatric Services Not Medically Necessary

32

46.97%

5D700/5H700

No/Invalid Plan of Treatment Present

31

3.03%

5J502/5K502

Information Submitted Does Not Support Dates Billed

2

1.52%

5D650/5H650

No/Invalid Certification/Recertification Present

1

North Carolina Results
A total of 431 claims were reviewed, with 55 of the claims either completely or partially denied. This resulted in a claim denial rate of 12.76 percent. The total dollars reviewed were $4,281,401.25, of which $534,423.61 were denied, resulting in a charge denial rate of 12.48 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

52.73%

5D800/5H800

Inpatient Psychiatric Services Not Medically Necessary

29

45.45%

5D700/5H700

No/Invalid Plan of Treatment Present

25

1.82%

5J502/5K502

Information Submitted Does Not Support Dates Billed

1

South Carolina Results
A total of 81 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 13.58 percent. The total dollars reviewed were $983,534.49, of which $158,605.33 were denied, resulting in a charge denial rate of 16.13 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

54.55%

5D700/5H700

No/Invalid Plan of Treatment Present

6

27.27%

5D800/5H800

Inpatient Psychiatric Services Not Medically Necessary

3

9.09%

5J502/5K502

Information Submitted Does Not Support Dates Billed

1

9.09%

5D650/5H650

No/Invalid Certification/Recertification Present

1

Virginia Results
No claims were reviewed in Virginia. 

West Virginia Results
No claims were reviewed in West Virginia. 
 

Denial Reasons and Prevention Recommendations

5D800/5H800 — Inpatient Psychiatric Services Not Medically Necessary

Reason for Denial
Documentation submitted for review did not support the medical necessity for inpatient psychiatric services. 

How to Avoid This Denial
In order to avoid denials for this reason, the documentation must provide clear evidence that the acute psychiatric condition being evaluated or treated requires active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting, including psychiatric partial hospitalization. There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting. 

In addition, you should submit a complete Psychiatric Evaluation. This evaluation should be completed within 60 hours of the patient’s admission to the Psychiatric facility. It should include a medical history, record of mental status; note the onset of the current illness and circumstances leading to admission; describe the behaviors and attitudes of the patient; estimate the intellectual functioning, memory and orientation; provide an inventory of the patient’s assets in a descriptive fashion. In addition to the evaluation, progress notes from all modalities should be submitted in the medical record.

More Information

  • 42 (CFR) Code of Federal Regulations, Section 412.27(c)(3) and 482.61
  • CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 20 and 30 (PDF, 102.76 KB)
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD L34570), which is available on the CMS website
     

5D700/5H700 — No Valid Plan of Treatment Present 

Reason for Denial
The Inpatient Psychiatric Facility claim was not covered because a valid multidisciplinary treatment plan was not included in the medical records submitted for review as required by Medicare.

How to Avoid This Denial
In order to avoid unnecessary denials for this reason, when responding to an Additional Development Request (ADR):

  • The multidisciplinary treatment plan should be developed by the physician and the treatment team within three day after the admission.
  • The multidisciplinary treatment plan must be signed by the mental health physician or there must be other signed documentation supporting the physician’s participation in the development and approval of the treatment plan
  • Ensure that the full multidisciplinary treatment plan is submitted for review. The plan should include both long- and short-term goals, certified diagnosis, treatment modalities to be utilized in the care of the beneficiary. 

More Information

  • 42 (CFR) Code of Federal Regulations, Section 412.27(c)(3) and 482.61
  • CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.3 (PDF, 102.76 KB)
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD L34570), which is available on the CMS website
     

5J502/5K502 — Information Submitted Does Not Support Dates Billed

Reason for Denial
The claim has been fully denied as the documentation submitted for review was not for the billing period requested in the additional documentation request (ADR). As a result, there were no orders for services or documentation of medical necessity for services billed. 

How to Avoid This Denial
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Ensure that the correct documentation is submitted for medical review by developing a procedure for staff to follow when preparing information in response to an ADR
  • Ensure documentation is for the DOS requested in the ADR
  • Ensure the documentation is for the beneficiary listed in the ADR

More Information

5D650/5H650 — No Valid Certification/Recertification Present

Reason for Denial
The Inpatient Psychiatric (IPF) claim was not covered because a valid certification/recertification signed by the physician was not included in the medical records submitted for review as required by Medicare.

How To Avoid This Denial
In order to avoid unnecessary denials for this reason, when responding to an Additional Development Request (ADR), the provider should ensure that the appropriate documentation to support certification/recertification is included and that it is signed by the mental health physician. A nonphysician provider (NPP) may not certify IPF claims. 

The initial certification should be completed at the time of admission or as soon thereafter as the patient’s condition reasonably allows. The physician must provide documentation that the services to be furnished on an inpatient basis can reasonably be expected to improve the patient’s condition or are for diagnostic study. There is no particular language or format required for the certification. It may be submitted on provider generated forms, in progress notes, in the records relating to the stay in question, however, it must be signed by the physician. If the certification is delayed it must be submitted with an explanation or other relevant evidence to justify the delay. 

Recertification should support that all services provided since the previous certification/recertification were, and continue to be, medically necessary that treatment is expected to improve the patient’s condition or is for diagnostic study. There should be documentation that the patient continues to require, on a daily basis, active treatment, and the supervision of inpatient psychiatric staff. The first recertification must be completed as of the 12th day of hospitalization. Each subsequent certification may be at intervals established by the psychiatric facility on a case-by-case basis; however, the interval is to be no longer than 30 days.

More Information

  • 42 (CFR) Code of Federal Regulations, Section 424.14
  • CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 2, Section 30.2.1(PDF, 102.76 KB)
  • CMS Internet-Only Manual (IOM), Pub 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 10.9 (PDF, 313.75 KB)
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD L34570), which is available on the CMS website
     

56900 — Auto Deny – Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request (ADR) is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
  • Gather all the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request (ADR) request to each individual claim
  • If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

More Information

The Next Steps
The service-specific postpayment medical review edits for DRG 885 — Psychoses in North Carolina, South Carolina, Virginia and West Virginia has been discontinued based on the resumption of Targeted Probe and Educate (TPE).

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to JM Redetermination: 1st Level Appeal form (PDF, 318 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 10/19/2021