HealthCare News

Acute Inpatient Service Expectations for Medical and Behavioral Health Admissions

Issue: #408 MAY2019

Topic: Reimbursement


To ensure quality care, facilities that provide acute medical and behavioral health inpatient services should meet the following expectations.

Prior to admission:

  • The facility must have the ability to accept admissions at any time and operate 24 hours a day, seven days per week, with medical and nursing services.
  • The initial evaluation and assignment of the diagnosis(es) must be completed and documented by an attending physician within 24 hours following the admission.
  • An individualized plan of care for the patient is required with an appropriate plan for discharge.

During admission, services must include:

  • A daily assessment with an attending physician or their designee (licensed independent practitioner) and appropriate documentation
  • A review of the plan of care under the direction of the attending physician as often as medically necessary and should include the multidisciplinary treatment team, the patient, family and other support as necessary
  • The availability of daily treatment, seven days per week
  • Medication management
  • Laboratory and other diagnostic services as needed
  • Discharge planning with social services

In addition, ongoing care must meet specific medical necessity criteria for the service requested.

If these criteria are not met, a penalty will be imposed on the Diagnosis-Related Group (DRG) payment and any associated professional charges for the member’s stay may be denied. This level of quality care is expected and necessary in this setting to ensure the acuity of the patient is being addressed in the appropriate setting.