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Contractor Information

Contractor Name: First Coast Service Options, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 09201 Contractor Type: MAC A

LCD Information

LCD ID Number: L33975 Status: A-Approved LCD Title: Psychiatric Inpatient Hospitalization Geographic Jurisdiction: Puerto Rico, Virgin Islands Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 01/01/2021 Revision End Date: CMS National Coverage Policy: This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Psychiatric Inpatient Hospitalization. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Psychiatric Inpatient Hospitalization and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.  Internet Only Manual (IOM) Citations:   CMS IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement, Chapter 4, Section 10.9 Inpatient Psychiatric Facility Services Certification and Recertification CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 2 Inpatient Psychiatric Hospital Services Chapter 4 Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation Chapter 5 Lifetime Reserve Days CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 130.1 Inpatient Hospital Stays for the Treatment of Alcoholism CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 40.4 Payment for Services Furnished After Termination, Expiration, or Cancellation of Provider Agreement, Section 50.1.3 Signature on the Request for Payment by Someone Other Than the Patient, Section 50.2.1 Inpatient Billing From Hospitals and SNFs, Section 50.2.2 Frequency of Billing for Providers Submitting Institutional Claims With Outpatient Services, Section 60.5 Coding That Results from Processing Noncovered Charges, Section 80.3.2.2 Consistency Edits for Institutional Claims, and Section 90 Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period Chapter 2, Section 30.6 Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility Data Chapter 3, Section 10.3 Spell of Illness and Section 20 Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs) CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD  Social Security Act (Title XVIII) Standard References:   Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.  Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.  Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.  Federal Register References:  CFR, Title 42, Volume 2, Chapter IV, Part 412.23 Excluded hospitals: Classifications, Part 412.27 Excluded psychiatric units: Additional requirements, Part 412.404 Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities, and Part 412.405 Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system CFR, Title 42, Volume 5, Chapter IV, Part 482.60 Special provisions applying to psychiatric hospitals, Part 482.61 Condition of participation: Special medical record requirements for psychiatric hospitals, and Part 482.62 Condition of participation: Special staff requirements for psychiatric hospitals. Sorry, you need to login or register to view additional sections of this Medicare policy. *