1. Acute Inpatient Hospitalization Services
Department of Medical Assistance Services
Acute Inpatient Hospitalization Services
DMAS Office of Behavioral Health
2013 1

2. Department of Medical Assistance Services
Disclaimer
These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations.
*Please refer to the manual, available on the DMAS website portal, for in-depth information on Psychiatric Services criteria. Providers are responsible for adhering to related state and federal regulations. 2

3. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Objectives of this Training Are:
To define the criteria of Acute Inpatient Hospitalization
To identify staff qualifications;
To clarify eligibility criteria;
To identify required activities;
To review limitations of the service;
To review criteria for discharge
To outline service reimbursement and service authorization requirements. 3

4. Acute Inpatient Hospitalization Service Definition
Department of Medical Assistance Services
Acute Inpatient Hospitalization Service Definition
DMAS Office of Behavioral Health
2013 4

5. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Treatment of acute psychiatric conditions in a psychiatric unit of a general, acute care hospital.
Treatment may include psycho-educational groups, socialization groups, behavioral interventions, individual counseling, play/art/music therapy, and play therapy. 5

6. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Definitions
Acute – within 24 hours
Active Treatment – implementation of a professionally developed and supervised individual Plan of Care
Ambulatory Care – services provided in the recipient’s home community.
On Admission – within 4 hours
Recent Onset – Within one week
Severe Psychiatric Disorder – clinical manifestation, symptoms, or complications which are so severe as to preclude diagnostic assessment and appropriate treatment in a less intensive treatment setting and require 24-hour nursing/medical assessment, intervention, or monitoring 6

7. Acute Inpatient Hospitalization Licensing
Department of Medical Assistance Services
Acute Inpatient Hospitalization Licensing
DMAS Office of Behavioral Health 7

8. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Acute Inpatient Hospitalization providers must have a Department of Behavioral Health and Developmental Services (DBHDS) license as a Psychiatric Unit. 8

9. Acute Inpatient Hospitalization Staff Qualifications
Department of Medical Assistance Services
Acute Inpatient Hospitalization Staff Qualifications
DMAS Office of Behavioral Health 9

10. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Therapy services may be provided by psychiatrists, clinical psychologist, school psychologist, licensed clinical social worker, licensed professional counselor, licensed psychiatric clinical nurse specialist, psychiatric nurse practitioner, or a licensed marriage and family therapist.
Therapeutic treatment interventions may be facilitated by nurses, social workers, psychologist, mental health workers, occupational therapists, and other appropriately prepared hospital staff. 10

11. Acute Inpatient Hospitalization Eligibility Criteria
Department of Medical Assistance Services
Acute Inpatient Hospitalization Eligibility Criteria
DMAS Office of Behavioral Health 11

12. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
In order to meet medical necessity criteria for acute inpatient, individuals must be found inappropriate for a lower level of care or ambulatory care as determined by one or more of the following:
Currently receiving ambulatory care and not responding to treatment; or
Identified condition is escalating; or
Condition is of an emergency nature with recent onset or is a reoccurrence of a previous acute psychotic condition; or
Condition requires monitoring of newly prescribed drugs with a high rate of complication or adverse reactions; or
Condition requires monitoring for toxic effects from therapeutic psychotropic drugs. 12

13. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Individuals admitted for inpatient hospital level of care must be diagnosed with a severe psychiatric disorder with evidence of recent onset of one of the following:
Current suicide attempt or ideation. Behavior reflecting a suicide attempt or suicidal intent with a plan. Degree of intent, availability of method, and immediacy of plan should support the decision to admit; or
Current assaultive, self-mutilative, or destructive behavior. Immediate danger to self or others is apparent. This behavior must require intensive psychiatric medial management and nursing interventions on a 24-hour basis; or 13

14. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Current hallucinations or bizarre or delusional behavior. Reality testing deficits or hypomanic behavior severe enough to present danger to self or others; or
Inability to perform activities of daily living because of severe psychiatric symptoms. This may include psychomotor retardation, severe depression, withdrawal, agitation, or catatonic behavior; or
Disorientation or memory impairment to the degree of endangering welfare; or
Loss of body control, total body rigidity, immobility, withdrawal or toxic seizures, or obsessive-compulsive behavior, which cannot be controlled. 14

15. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
The following disorders do not justify acute inpatient unless medical necessity previously listed is also met:
Organic Brain Syndrome
Hyperactivity
Attention Deficit Disorder
Dyslexia
Personality Disorders
Eating disorders
Substance Abuse
Intellectual Disabilities
Alzheimer’s disease 15

16. Acute Inpatient Hospitalization Required Activities
Department of Medical Assistance Services
Acute Inpatient Hospitalization Required Activities
DMAS Office of Behavioral Health 16

17. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Eligibility for Continued Stay after Admission
The intensity of treatment must relate to the severity of illness with the goal of improving or preventing regression of the condition.
The active treatment plan must reflect one of the following:
Physical restraint/seclusion/isolation; or
Suicidal/homicidal precautions; or
Escape precautions; or
Drug therapy requiring specific close medication supervision; and
All of the following: 17

18. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
A licensed professional provides therapy on at least 5 out of 7 days. In addition at least one treatment intervention occurs on the same days.
On days with no therapy there must be at least two appropriate treatment interventions which may include psycho-educational or socialization groups, behavioral interventions, counseling, play/art/music therapy, and/or occupational therapy which may be facilitated by appropriately trained hospital staff, nurses, or social workers.
The family, caretaker, or case manager is involved on an ongoing basis with treatment planning and participating a minimum of once per week unless documented otherwise.
Active treatment and discharge planning begin at admission. 18

19. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Therapeutic Passes
One day pass is allowed if the goal of the pass is documented prior to the day of the pass and if, on return, the effect of the pass is documented.
If the first day pass is determined not to have reached the goals a second pass may be permitted.
Day passes, which are not part of the treatment plan or documented as to have therapeutic effect are not permitted.
Overnight passes are not permitted 19

20. Acute Inpatient Hospitalization Limitations
Department of Medical Assistance Services
Acute Inpatient Hospitalization Limitations
DMAS Office of Behavioral Health 20

21. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
For individuals 21 years of age and older, coverage is for medically necessary days, up to 21 days within a 60 day period for the same or similar diagnosis.
The 60 day period begins with the first approved day of a hospital admission.
This limitation applies whether the days are incurred in one or more hospital stays or in the same or multiple hospitals.
* Under age 21 additional days are allowed if medically necessary 21

22. Acute Inpatient Hospitalization Discharge Criteria
Department of Medical Assistance Services
Acute Inpatient Hospitalization Discharge Criteria
DMAS Office of Behavioral Health 22

23. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Continued hospital level-of-care is not appropriate and will not be covered when one or more of the following exist:
The stabilization of presenting symptoms with demonstrated ability to perform Activities of Daily Living (ADLs) appropriate for age and to function appropriately within hospital environment; or
The required treatment can be provided in a less restrictive environment; or
The type or dosage of major psychotropic medication has been unchanged for the last five days or there is medical documentation to support no variation in drug therapy; or
There has been no documented evidence of a change in treatment plan when the individual has not responded in a seven-day period; or
The individual refuses to cooperate with the treatment plan. 23

24. DMAS Office of Behavioral Health
Department of Medical Assistance Services
Acute Inpatient Hospitalization Reimbursement and Service Authorization
DMAS Office of Behavioral Health 24

25. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
DMAS pays an all-inclusive rate. However, the professional component for the psychiatric care may be billed separately.
Hospital rates can be found at:
Refer to the Hospital Provider Manual, Chapter IV, for specific, additional requirements for acute care facilities. 25

26. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
KePRO is the DMAS contractor for Service Authorization (SA). For questions go to the SA website: DMAS.KePRO.org and click on Virginia Medicaid Phone: VAPAUTH or Fax: OKBYFAX or Web: 26

27. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Submitting a request
The preferred method is through the Atrezzo® web-based program
Registration is required
Information on Atrezzo is available on the KePRO website, or call or (804) or mail to:
KePro
2810 North Parham Rd, Suite 305
Henrico, Virginia 23294 27

28. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Authorization is required for inpatient hospitalizations either prior to admission or on the next business day after admission.
Prior to the expiration of the initial assigned length of stay, if the individual requires continued hospital care, the health care provider must contact the SA contractor to initiate the concurrent review process.
The reviewer will apply InterQual® ISD-AC criteria to the medical information provided and assign an additional length of stay if criteria are met for continuation of inpatient hospitalization. 28

29. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Many Medicaid recipients are enrolled with one of the Departments contracted Managed Care Organizations (MCO).
For an MCO enrolled individual, providers must contact and follow the MCO’s contract.
The MCO may utilize different service authorization, billing, and reimbursement guidelines than those described in this training.
For more information providers may contact the MCO directly or find additional information about the Medicaid MCO program at: 29

30. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Helpful Resources:
Virginia Medicaid Web Portal link
DMAS Office of Behavioral Health:
Address
DMAS Helpline: Richmond Area
All other 30

31. Acute Inpatient Hospitalization
Department of Medical Assistance Services
Acute Inpatient Hospitalization
Thank you for attending this training and helping to serve Virginia’s Medicaid Recipients. 31