Reason Code 5D800: Inpatient Psychiatric Services Not Medically Necessary
Documentation submitted for review did not support the medical necessity for inpatient psychiatric services.
To Prevent This Denial
- In order to avoid denials for this reason, the documentation must provide clear evidence that the acute psychiatric condition being evaluated or treated requires active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting, including psychiatric partial hospitalization. There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting.
- In addition, you should submit a complete Psychiatric Evaluation. This evaluation should be completed within 60 hours of the patient’s admission to the psychiatric facility. It should include a medical history, record of mental status; note the onset of the current illness and circumstances leading to admission; describe the behaviors and attitudes of the patient; estimate the intellectual functioning, memory and orientation; provide an inventory of the patient’s assets in a descriptive fashion. In addition to the evaluation, progress notes from all modalities should be submitted in the medical record.
- Code of Federal Regulations, 42 CFR – Section 412.27 and 482.61 (PDF, 142 KB)
- CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Publication 100-02, Chapter 2, Section 30.3 (PDF, 103 KB)
- Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the CMS website