MHCP covers inpatient hospitalization for detoxification when conditions resulting from withdrawal or occurring in addition to withdrawal require constant availability of a physician and registered nurse or complex medical equipment found only in an inpatient hospital setting. Although inpatient hospital authorization (IHA) is not required, the medical review agent may review the recipient’s medical records retrospectively for any claims paid under one of the chemical dependency DRGs.
MHCP does not cover inpatient hospitalization for a withdrawal diagnosis without concomitant medical and/or psychiatric needs.
The following guidelines are appropriate for use in a medical or psychiatric unit. Detox in a medical unit may be easier to justify due to definitive physical symptoms, e.g. elevated BP, temp, pulse, or cognitive changes without overt behavioral symptoms. It is the responsibility of the hospital and physician to provide to the medical review agent the clinical information needed to justify inpatient admission.
The medical review agent uses the following guidelines in conjunction with the Hospital Admission Certification criteria to determine appropriateness of inpatient acute care hospitalization for MHCP recipients experiencing signs and symptoms of alcohol and drug withdrawal.
Possible pre-admission information:
• Identify where/how the recipient presented to the hospital (through the ED, MD’s office, police), whether or not the recipient was suicidal, or recipient’s medical condition was unstable
• Determine how the recipient was initially registered and whether or not services were provided as an outpatient (observation) before inpatient admission (MHCP covers outpatient observation before inpatient admission up to 48 hours but is not a requirement)
• For recipients admitted as inpatients, determine the reason the recipient was unable to return to the county detox center/unit, unable to be discharged, or unable to transfer to CD treatment (i.e., did the clinical picture fall outside the parameters these facilities were able to treat)
• Determine if the reason for the outpatient observation stay was/was not the reason for inpatient admission. A non-definitive diagnosis, change in the clinical picture, or a progression of symptoms from the initial presentation is not uncommon. For example, a recipient may be intoxicated and suicidal while in the ED; however, after 23 hours, the recipient was no longer suicidal but in acute alcohol withdrawal delirium. Both the initial and subsequent symptoms should be documented in the medical record
• Patient management of alcoholic psychoses may occur on a medical unit or psych unit. The physical location of the recipient is a clinical decision based on individual recipient needs and the facility’s ability to treat the recipient in the safest, most effective way.
• Blood alcohol level (BAL), breathalyzer and/or urine toxicology screen (quantitative and qualitative)
Use the BAL or breathalyzer level determined when the recipient first presented for detoxification. If the BAL or breathalyzer was first drawn on admission to a detox center or in the ED, then drawn the following day, consider the highest level in addition to objective signs of withdrawal. Since full blown withdrawal symptoms may not be exhibited for 18-48 hours after cessation of consumption, using the most recent BAL could misrepresent the potential medical risk to the recipient. The half-life of ETOH is short and the level can drop precipitously within 12 hours (i.e., an extremely high level in the evening when the recipient is low risk for withdrawal could be low the following day when the recipient becomes a higher risk for withdrawal).
• Documentation of objective acute withdrawal/detoxification signs and symptoms
• Receiving medications for withdrawal once the recipient is no longer “intoxicated” (for alcohol withdrawal, typically a fast-acting benzodiazepine); for a recipient requiring inpatient hospitalization, medications are ordered on a regular schedule, not PRN; time and dose of medication administration may be determined through use of an alcohol withdrawal assessment tool (sliding scale)
• If CD treatment under Rule 25 is appropriate, detox criteria are not met if the recipient is being held on psych while waiting a Rule 25 assessment and determination of coverage unless medical criteria are met. Review the severity of withdrawal. Inpatient detox is appropriate if the recipient is in alcoholic or drug withdrawal psychosis, continues to be actively suicidal following outpatient observation, or has other acute medical needs beyond the withdrawal management
• Physician and nursing documentation of objective symptoms are the final determination of whether the recipient was in alcoholic or drug psychoses. Examples of symptoms include hypertensive crisis, seizures, autonomic hyper-arousal, delirium, and alcoholic hallucinosis
• Bill inpatient medical detoxification and/or treatment of sequelae resulting from drug or alcohol ingestion in the same way as any other acute inpatient admission
• Do not bill according to the Consolidated Chemical Dependency Treatment Fund (CCDTF) guideline
Minnesota Rules 9505.0530 Incorporation by reference of criteria to determine medical necessity
MHCP Provider Manual:
42CFR440.10 Inpatient hospital services, other than services in an institution for mental diseases
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42CFR440.20 Outpatient hospital services and rural health clinic services