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7.16 Psychiatric Services for Hospitals
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid. Admissions must be medically necessary and are subject to the Texas Medicaid's retrospective UR requirements. The UR requirements are applicable regardless of the hospital's designation of a unit as a psychiatric unit versus a medical/surgical unit.
Clients 20 years of age or younger may be admitted to a freestanding psychiatric facility or a state psychiatric facility. Clients 21 years of age or older may be admitted only to an acute care facility. A certification of need must be completed and placed in the client's medical record within 14 days of the admission or once the client becomes Medicaid eligible while in the facility.
Inpatient psychiatric treatment is a benefit of Texas Medicaid if all the following apply:
• The client has a psychiatric condition that requires inpatient treatment.
•The inpatient treatment is directed by a psychiatrist.
•The inpatient treatment is provided in a nationally accredited facility or hospital.
•The provider is enrolled in Texas Medicaid.
Inpatient admissions for the single diagnosis of chemical dependency or abuse (such as alcohol, opioids, barbiturates, and amphetamines) without an accompanying medical complication are not a benefit of Texas Medicaid. Additionally, admissions for chronic diagnoses such as mental retardation, organic brain syndrome, or chemical dependency or abuse are not covered benefits for acute care hospitals without an accompanying medical complication or medical condition. The UB-04 CMS-1450 paper claim form must indicate all relevant diagnoses that necessitate the inpatient stay.
Supporting documentation (certification of need) must be documented in the individual client's record. This documentation must be maintained by each facility for a minimum of five years and be readily available for review when requested by HHSC or its designee.
Additional coverage may be allowed for clients who are eligible for Medicaid and birth through 20 years of age through the THSteps-Comprehensive Care Program (CCP). Use revenue code 124 to bill for inpatient psychiatric services.
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