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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6. Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.14 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 Texas Medicaid’s retrospective utilization review (UR) requirements. The UR requirements are applicable regardless of the hospital’s designation of a unit as a psychiatric unit versus a medical or surgical unit.
Clients who are 20 years of age and younger may be admitted to a freestanding psychiatric facility or a state psychiatric facility. Clients who are 21 years of age and older may be admitted only to an acute care facility. Providers should use the most appropriate revenue code when billing for inpatient psychiatric services in 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:
Clients of all ages may be admitted to an acute care facility. 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 benefits of Texas Medicaid. Additionally, admissions for chronic diagnoses such as intellectual disability, 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 client’s medical 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 through the Comprehensive Care Program (CCP) may be allowed for Medicaid-eligible clients who are 20 years of age and younger. Providers should use revenue code 124 when billing for inpatient psychiatric services in freestanding and state psychiatric facilities.
Refer to:
Section 2.11, “Inpatient Rehabilitation Facility (Freestanding) (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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