Medication Management, Medical Necessity and Residential Care

Psychiatric TimesPsychiatric Times Vol 18 No 3
Volume 18
Issue 3

The National Alliance for Research in Schizophrenia and Depression awarded the 2000 Nola Maddox Falcone Prize. A brief description of each recipient's contributions to research with affective disorders is given.

It was once estimated that one-third of chronic psychotic patients in California live in residential care homes (Lamb and Goertzel, 1977). Despite this fact, there is very little recent literature about this population and how they should be treated. For example, is follow-up best done on the premises or in an office or clinic setting? How often is follow-up required? Typically, psychiatrists visit these homes once or twice a month and order medications for most of the residents, to be dispensed by the staff at prescribed times. A study done before the advent of atypical antipsychotics reported that the average board-and-care resident was visited by a psychiatrist 1.72 times per month and received an average dose of 760 mg of chlorpromazine (Thorazine) or chlorpromazine equivalents (van Putten and Spar, 1979).

Residential care psychiatry has undergone a rapid evolution in the past 10 years. In a series of articles (Fleishman, 1985, 1989, 1990), I have described the characteristics of board-and-care psychiatry along with recent changes that have added to the complexity of the medication management of patients in these homes (Fleishman, 1997). Among these changes is the development of new medications, many of which may accelerate or inhibit the metabolism of other drugs. Other changes are the rise of atypical agents now regarded by many as first-line treatment for schizophrenia, the increasing necessity to follow drug treatment with laboratory tests and the increased frequency of U.S. Food and Drug Administration mandates for boxed warnings for rare side effects. Examples of this are the prolongation of the QTc interval with thioridazine (Mellaril) and the occurrence of pancreatitis with divalproex sodium (Depakote). Additional complexities have been created by the emergence of more sophisticated treatment algorithms in which polypharmacy is presented as a viable alternative when patients do not respond to single drugs (Suppes et al., 1995).

Adding to this complexity is the tendency to release even the most disturbed patients from community and state hospitals and other long-term facilities because of the increased costs associated with institutionalization. For many of these patients, stabilization is dependent on complicated pharmacological regimens that may include typical antipsychotics, atypical antipsychotics, antidepressants, anticonvulsants, minor tranquilizers, b-blockers, antiparkinsonian agents, lithium and stool softeners.

Sometimes these combinations are little more than hastily contrived pastiches in which a little bit of this and a pinch of that have been pasted onto a pre-existent menu of anti-somethings, following which the patient is released into the community-ocean, wherein the dangers of drowning replace the perils of decertification. More often, these combinations are carefully conceived and represent the best possible option to preserve psychiatric stability. The fact is that the medication management of psychiatric patients is more complicated than ever before and more effective than ever before in terms of facilitating the release of severely disturbed patients from long-term facilities.

Because of these factors, medication management of psychiatric outpatients in residential care facilities and elsewhere has become very expensive. For instance, the cost of a maintenance dose of olanzapine (Zyprexa) alone averages $270 per month (at 10 mg per day). Many patients need supplementary psychiatric medications, as well as treatment for nonpsychiatric concurrent diseases such as arthritis, diabetes, heart disease, hypertension and hypercholesterolemia-to name only a few-that also require treatment with medication. Despite this, the cost of treating mental illness is frequently based on estimates restricted to psychiatric medications.

Unfortunately, these cost increases are coming at a time when there is growing pressure on managed care providers, third-party payers and government agencies to reduce the financial burden of health care and entitlements, balance the federal budget, and resolve the perceived threat of imminent Medicare insolvency within the next decade. Consequently, all health care providers will come under increasing pressure by federal agencies to justify their roles.

The legislative mechanism for such oversight is the Health Insurance Portability and Accountability Act of 1996 (HIPAA), otherwise known as the Kennedy-Kassebaum Act. HIPAA requires that the U.S. Department of Health and Human Services set up a health care fraud program that will coordinate the efforts of federal, state and local law enforcement agencies to investigate the delivery of health care to both public and private health plans. Moreover, HIPAA establishes an account that is funded by civil monetary penalties, criminal fines and other penalties collected from successful prosecutions and authorizes the use of these funds to finance additional health care fraud prosecutions. HIPAA also provides for whistleblower rewards based on a percentage of recovered monies and enables the agency to impose civil monetary penalties for certain actions including upcoding, providing unnecessary services and false certification of home health care services.

These penalties are described as modifications of the Social Security Act, in language not notable for its clarity. Thus, the violation of upcoding is covered under section 231 of HIPAA in the section entitled "Social Security Act Civil Monetary Penalties." Within this section there is a paragraph that reads,

Modification of Amounts of Penalties and Assessments-Section 1128A(a) (42 U.S.C. 1320a-7a(a)), as amended by subsection (b), is amended in the matter following paragraph 4-(1) by striking $2,000 and inserting $10,000.

Not only does this mean that there is now a $10,000 penalty on a per service basis for using the wrong code, but the following paragraph entitled "Clarification of Knowledge Required for Imposition of Civil Monetary Penalties" specifies that no specific intent to defraud is necessary.

Similarly horrendous penalties exist on a per-service basis for providing services that may be regarded as medically unnecessary. And how does one judge medical necessity in psychiatry? The American Psychiatric Association has adopted the American Medical Association's definition of medical necessity piecemeal, possibly in deference to the parity concept that all physicians should be treated equally. Medical necessity is defined as:

Health care products or services that a prudent physician would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, level, site and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider.

It is questionable whether such a definition is useful in the evaluation of psychiatric services, insofar as the frequency or length of psychotherapy sessions can be interpreted as something done for the patient's convenience. One patient's necessity may be downgraded to another patient's convenience, depending on an auditor's opinion. I believe medical necessity should be regarded as a complex decision reached primarily by the psychiatrist, but subject to independent psychiatric reviews based on the needs of the patient. The determination of psychiatric medical necessity should also involve information from the patient's family, legal representatives and other professionals involved in the care of the patient, as well as nonprofessionals involved in caretaking.

The current AMA-APA definition does not acknowledge these external contributions. They are, however, very important because-unlike other medical specializations-in psychiatry we frequently treat patients who are unreliable historians or who even deny illness entirely. It is conceivable that an auditor might not think that the input of a social worker or nonprofessional caretaker is important in the determination of medical necessity, given the current APA-AMA definition, when such input may be of crucial importance.

There are additional problems for those using psychopharmacological codes (which tend to be the more frequently used in residential care facilities). The March 2000 Medicare Bulletin for Northern California addressed the issues of psychiatric pharmacotherapy and reflected the policies of the 24 Medicare Part B Carriers. Psychiatric medication management is now divided into two separate codes, 90862 and M0064. The first, 90862, continues to be defined as pharmacological management including prescription, use and review of medication with no more than minimal medical psychotherapy, but with the added restriction that 90862 refers to an in-depth assessment because the drugs that are used are potent medications with serious side effects. The Bulletin goes on to say that 90862 should not be used to bill for a simple dosage adjustment of long-term medication. On the other hand, M0064 is to be used when the patient is stable but requires pharmacological oversight. In the descriptor for M0064, the phrase "potent medications with serious side effects" is not used, even though presumably we are talking about the same drugs coded by 90862.

Psychiatrists now face a Hobson's choice. If they use the 90862 code, they must justify the unclear in-depth criteria in their progress notes or face the possibility of a $10,000 upcoding violation. If psychiatrists use the M0064 option, they may incur the $10,000 fine for rendering unnecessary medical services because there are no published articles quantifying the appropriate frequency of services rendered to patients who are stable. Barring explicit Medicare instructions, at this point we simply do not know what an acceptable level of frequency is for M0064 services, although the Bulletin acknowledged that, for some patients, 90862 services may be rendered as 18 or less services within a 12-month period. In other words, psychiatrists are faced with the question of which $10,000 penalty they wish to incur-the one that comes with upcoding or the one that comes with medical necessity.

If this were not enough, those psychiatrists working in residential care facilities or residential treatment facilities (half-way houses or locked facilities) are faced with an additional hazard. Their more frequent use of medication management codes compared to office-based practices creates an outlier aberrant service code profile, which is sufficient to trigger a computer-based audit.

Unfortunately, the impetus for these punitive laws is the widespread existence of health care fraud by physicians, other health care providers, HMOs, laboratories and even prestigious university hospitals. The extent of fraud is staggering and is believed to be as high as 10% of the approximately $1 trillion that Americans spend every year on medical treatment (Grinfeld, 1997). The fact is that Medicare was basically an honor system that didn't work because the rules were dishonored by too many dishonorable people. In short, somebody had to do something. Although the above factors severely affect the on-site services of psychiatrists to any type of residential care or treatment facility, they also impact all psychiatrists who utilize medication management codes.

With the above factors in mind, it might be well for the psychiatric profession to reconsider the sock-like one-size-fits-all APA-AMA definition of medical necessity. What works for socks may not work for shoes. Like it or not, psychiatry as a specialization has distinctive contours that require a more customized approach, and the following definition is offered as an approximation of what such a definition might encompass:

The definition of medical necessity in psychiatry pertains to health care services that a prudent physician would provide to a patient for the purpose of diagnosing and treating a psychiatric illness in a manner that is in accordance with generally accepted community standards of psychiatric practice and clinically appropriate in terms of type, frequency, level, site and duration. The medical necessity of any individual service is a complex decision reached primarily by the treating psychiatrist but subject to the review of an independent psychiatrist, while taking into consideration the needs of the patient, and may involve additional information derived from the patient's family, the patient's legal representatives, other professionals involved in the care of the patient and nonprofessionals involved in a caretaking capacity.




Fleishman M (1997), The changing role of the psychiatrist in board-and-care homes. Psychiatr Serv 48(4):510-513.


Fleishman M (1990), Board-and-care psychiatry and the treatment of the seriously mentally ill. In: Psychiatry Takes to the Streets: Outreach and Crisis Intervention for the Mentally Ill, Cohen NL, ed. New York: Guilford Press.


Fleishman M (1989), The role of the psychiatrist in board-and-care homes. Hosp Community Psychiatry 40(4):415-418.


Fleishman M (1985), Board and care homes, 1984: return of the house call. Psychiatric Annals 15:654-665.


Grinfeld MJ (1997), Mental health targeted as Medicare, Medicaid expenditures grow. Psychiatric Times 14(5):58.


Lamb HR, Goertzel V (1977), The long-term patient in the era of community treatment. Arch Gen Psychiatry 34(6):679-682.


Suppes T, Calabrese JR, Mitchell PB et al. (1995), Algorithms for the treatment of bipolar manic-depressive illness. Psychopharmacol Bull 31(3):469-474.


van Putten T, Spar JE (1979), The board-and-care home: does it deserve a bad press? Hosp Community Psychiatry 30(7):461-464.

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