SUBJECT: Use of Outpatient Drug and Alcohol Rehabilitation services billed with Rev Codes 944 and 945

PURPOSE
The purpose of this notice is to update the provider community of issues surrounding the Progressive Corrective Action (PCA) service wide review for Outpatient Drug and Alcohol Rehabilitation conducted by Highmark Medicare Services and to remind providers of the indications and limitations of coverage and medical necessity guidelines for Outpatient Drug and Alcohol Rehabilitation as described by Medicare.  This notice is also intended to assist in decreasing the claims error rate and to avoid provider denials for the above listed service.

BACKGROUND
Outpatient psychiatric services represent a variety of ambulatory psychiatric services used to provide active treatment to individuals with mental disorders. Other than certain diagnostic tests, these services are provided incident to the services of a psychiatrist or other physician (M.D. or D.O.) trained in the treatment of psychiatric disorders.

In order for Drug and Alcohol Rehabilitation related Outpatient psychiatric services to be reimbursed by Medicare, the documentation should reflect the medical necessity and that the services were rendered. 

REVIEW SUMMARY
The information provided below is based on a service wide review of submitted claims for Drug and Alcohol Rehabilitation services from January 1, 2006 through August 31, 2006.  Medical review of claims for Outpatient Drug and Alcohol Rehabilitation services for the above mentioned dates continues to show an overall error rate of 93%. 

As a result of this high error rate PCA action was initiated. The majority of the denials were due to insufficient or missing documentation required to make payment.  Specific documentation that is helpful in determining the rationale for Outpatient Psychiatric Drug and Alcohol Rehabilitation services is listed on the Additional Development Request (ADR) letter.  An ADR is mailed to the provider requesting specific documentation for each claim to be medically reviewed.  The ADR information follows:

(All Documentation Must Be Present To Support Medical Necessity)                                                      

• The beneficiary’s diagnosis and any history of treatment for the diagnosis or associated conditions. 
• An individual treatment plan established by a physician is required if the psychosocial services are furnished for more than five sessions.
• A statement or documentation that the services are being supervised and evaluated by a physician.
• Documentation to support the patient’s response to the treatment provided.
• Attendance records and documentation denoting each treatment team member’s component billing of psychiatric services.
• Documentation to support all services billed.
• Itemized Bill

It is very important that providers obtain necessary medical documentation from third parties such as physicians or other providers, health care facilities, or suppliers to fully support the services billed to Medicare.  It is the responsibility of the provider submitting the claim for payment to obtain all the requested documentation, regardless of where the records are kept.

When a request for Additional Development Request (ADR) is received, please review and provide the requested documentation prior to submission of claims in order to ensure appropriate review of all information supporting medical necessity for the services billed.
                                                       
In regards to the review of claims from 01/01/06 to 08/30/06, the review revealed that most providers are sending in documentation when requested by the Additional Development Request (ADR) in a timely manner.  However, significant pieces of the documentation are often missing, such as documentation that supports an unequivocal diagnosis, insufficient documentation to medically justify the service, missing or incomplete history and physical, missing initial evaluation by the physician, and documentation to support the services were supervised and periodically evaluated by a physician as indicated under coverage criteria,

In summary, the purpose of this notice is to update the provider community of issues surrounding the Progressive Corrective Action (PCA) service wide review for the use of Outpatient psychiatric Drug and Alcohol Rehabilitation services conducted by Highmark Medicare Services to assist in decreasing the claims error rate and to avoid provider denials of the above listed service.

This is an LPET publication. You may contact Highmark Medicare Services. Please continue to check the Highmark Medicare Services website for informational bulletins, provider notices and policy updates.

• Medicare Intermediary Manual 3112(7)(B)(3)
• Medicare Hospital Manual, section 230.4
• Medicare Hospital Manual, section 230.5
• Medicare Coverage Issues Manual, section 35.22

If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170