Inpatient Hospitalization for Detoxification Guidelines

Revised: July 19, 2021

· Overview

· Guidelines

· Billing

· Additional Resources

Overview

Minnesota Health Care Programs (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 Department of Human Services (DHS) may conduct concurrent, continued stay and retrospective reviews. DHS will consult a medical review physician adviser if the medical record and other supporting information do not clearly demonstrate the medical necessity of the admission and continued stay services provided.

MHCP does not cover inpatient hospitalization for a withdrawal diagnosis without accompanying medical or psychiatric needs.

Guidelines

The following guidelines are appropriate for use in a medical or psychiatric unit. It is the hospital’s and physician’s responsibility to provide the medical review agent with 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 members experiencing signs and symptoms of alcohol and drug withdrawal.

Possible pre-admission information:

· Identify where or how the member presented to the hospital (through the Emergency Department, physician’s office, police), whether or not the member was suicidal, or the member’s medical condition was unstable

· Determine how the member 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 members who are admitted, determine the reason the member was unable to return to the county detoxification center or unit, unable to be discharged, or unable to transfer to chemical dependency (CD) treatment (for example, did the clinical status fall outside the parameters these facilities were able to treat)

· Determine if the reason for the outpatient observation stay was or was not the reason for inpatient admission. It is not uncommon for a patient to have a non-definitive diagnosis, a change in the clinical status, or a progression of symptoms from the initial presentation. For example, a member may be intoxicated and suicidal while in the Emergency Department; however, after 23 hours, the member may no longer be 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 psychiatric unit. The physical location of the member is a clinical decision based on the individual member’s needs and the facility’s ability to treat the person in the safest, most effective way.

Examples of Medical Management

· Blood alcohol level (BAL), breathalyzer and urine toxicology screen (quantitative and qualitative).
Use the BAL or breathalyzer level determined when the member first presented for detoxification. If the BAL or breathalyzer was first drawn on admission to a detoxification center or in the Emergency Department, then drawn again the following day, consider the highest level in addition to objective signs of withdrawal. Since full-blown withdrawal symptoms may not exhibit for 18-48 hours after cessation of consumption, using the most recent BAL could misrepresent the potential medical risk to the person. The half-life of alcohol is short and the level can drop rapidly within 12 hours (for example, an extremely high alcohol level in the evening when the member is low risk for withdrawal could be low the following day when the member becomes a higher risk for withdrawal).

· Documentation of objective acute withdrawal or detoxification signs and symptoms

· Receiving medications for withdrawal once the member is no longer “intoxicated” (for alcohol withdrawal, typically a fast-acting benzodiazepine); for a member requiring inpatient hospitalization, medications are ordered on a regular schedule, not as needed; time and dose of medication administration may be determined through use of an alcohol withdrawal assessment tool (sliding scale)

· If chemical dependency treatment under Rule 25 or a comprehensive assessment is appropriate, but detoxification criteria are not met, the member should not be held in a psychiatric unit while waiting a Rule 25 assessment and determination of coverage unless the medical criteria are met. Review the severity of withdrawal. Inpatient detoxification is appropriate if the member 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 member was in alcoholic or drug psychoses. Examples of symptoms include hypertensive crisis, seizures, autonomic hyper-arousal, delirium and alcoholic hallucinosis

Billing

· Bill inpatient medical detoxification 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 Behavioral Health Fund (BHF) guidelines.

· Do not combine chemical dependency (CD) rehabilitation services with detox services. Bill for the CD rehabilitation services separately.

Additional Resources

Minnesota Rules, 9505.0530 (Incorporation by Reference of Criteria to Determine Medical Necessity)

MHCP Provider Manual:

· Hospital Services

· Inpatient Hospital Authorization

Code of Federal Regulations, title 42, section 440.10 (Inpatient hospital services, other than services in an institution for mental diseases)
Code of Federal Regulations, title 42, section 440.20 (Outpatient hospital services and rural health clinic services)