Ala. Admin. Code r. 560-X-41-.10

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-41-.10 - Inpatient Utilization Review

(1) The determination of the level of care will be made by a licensed nurse of the hospital staff.

(2) Five percent of all admissions and concurrent stay charts will be retrospectively reviewed by the Medicaid Agency or designee on a monthly basis.

(4) For an individual who is a Medicaid recipient at the time of admission, the attending physician must sign a Psychiatric Admission for including the medical necessity of the admission.

(4) For an individual who applies for Medicaid while in the facility, a Psychiatric Admission form must be signed by the attending physician at the time application for Medicaid is made.

(5) The following information shall be included on the Physician Admission Form:

(a) Recipient information:

1. admitting diagnosis;

2. events leading to hospitalization;

3. history of psychiatric treatment;

4. current medications;

5. physician orders;

6. presenting signs and symptoms.

(b) Events leading to present hospitalization.

(c) Diagnosis within the ICD-9 range of 290-316 (dates services prior and up to September 30, 2015} or ICD-10 range of F01.50 - F69, F80.0 - F99, G44.209, H93.25, R37, R45.1 - R45.2, R45.5 - R45.82, R480, Z87.890 (dates of services October 1, 2015 and forward.

(d) History and physical.

(e) Mental and physical capacity.

(f) Summary of present medical findings including prognosis.

(g) Plan of care.

(6) Medicaid's Psychiatric Criteria for Psych Under 21 will be utilized in reviewing whether the admission and continued stay were appropriately billed.

Ala. Admin. Code r. 560-X-41-.10

Rule effective September 13, 1989. Emergency rule effective August 21, 1991. Amended effective November 13, 1991. Amended: Filed May 6, 1994, Effective Date June 14, 1994. Amended: Filed August 7, 2000; effective September 11, 2000. Amended: Filed November 8, 2001; effective December 13, 2001. Amended: Filed September 11, 2012; effective October 16, 2012.

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 12, September 30, 2015, eff. 10/1/2015.

Authors: Solomon Williams, Associate Director, Institutional Services

Statutory Authority: Title XIX, Social Security Act; State Plan, Attachment 3.1-A, pp. 7, 7.16; 42 C.F.R §§ 456.170 - .171.