MANAGED CARE:
Psychiatric Consultation Services for Medical/Surgical Patients

RECOMMENDATIONS

Psychiatric consultation services for medical/surgical patients have historically been covered by traditional health insurance plans. The increased prevalence of mental health carve-outs from managed care plans has led to significant problems in providing these important services. The following recommendations are intended to address these needs and should be utilized in the development and negotiation of institutional agreements and/or managed care contracts.

Recommendation I:

All managed care contracts should include specific plans to cover psychiatric consultation services to medical/surgical inpatients.

Recommendation II:

Psychiatric consultation services for medical/surgical inpatients should be specifically covered under general medical capitation, comparable to other specialty consultations to medical inpatients.

Recommendation III:

Whether psychiatric consultation services to medical/surgical inpatients are covered through a behavioral healthcare "carve-out" or included in the general medical plan, the following guidelines are recommended.

1. Psychiatric consultations in the inpatient medical setting should be reimbursed under the following conditions.
    
   1. Psychiatric consultation is requested by the attending physician responsible for patient's care during inpatient medical hospitalization.
       
   2. Medical necessity is documented by the attending physician. Examples of medical necessity include, but are not limited to (see appendix):
       
      • Suicidal ideation, intent or plan
      • Homicidal ideation or plan
      • Acute agitation
      • Chronic and persistently mentally ill patients with comorbid general medical illnesses
      • Substance abuse or detoxification
      • Constant observation for imminent dangerousness
      • Severe noncompliance or treatment refusal
      • Cognitive impairment
      • Assessment of significant:
        • Depression
        • Anxiety
        • Acute or chronic pain
        • Persistent physical complaints with suspected psychogenic etiology
      • Evaluation of competency to consent to medical procedures
      • Management of complex comorbid medical and psychiatric conditions; e.g., emphasis on drug/drug interactions
      • Routine evaluations in specialized high-risk medical settings such as solid organ and bone marrow transplant programs

2. Psychiatric consultations should be performed ONLY by psychiatrists who are credentialed and privileged for these services at the institution where the patient is hospitalized. Treatment may then be delegated to other behavioral healthcare specialists under the clinical supervision of the consulting psychiatrist.
    
3. The initial consultation, and at least one follow-up visit, should be automatically covered without pre-certification.
    
4. Specific authorization for medical necessity may be required for further visits.
    
5. The managed care organization will review the utilization of psychiatric consultations.

Additional Recommendations:

Regardless of funding mechanisms, three other recommendations are offered:

1. Follow-up treatment for psychiatric problems related to medical condition (i.e., AIDS, cancer, renal failure, diabetes, etc.) should be provided, if possible, at the same treatment facility where the patient receives primary medical care.
    
2. When transfer of a medical patient to a psychiatric inpatient setting is required, preference should be given to transfer within the facility where he/she is receiving medical care.
    
3. Psychiatrists expert in the provision of psychiatric care to the medically ill should be included in the development of mental health/primary care linkages. Specifically, such individuals should participate in "coordination of care" agreements between the medical care providers and behavioral health providers.

(Table 2 from Practice Guidelines for Psychiatric Consultation in the General Medical Setting. Bronheim H, et al, Academy of Psychosomatic Medicine)

1. Suicide Assessment
2. Depression
3. Panic/Anxiety
4. Agitation/Anger
5. Bizarre/Unexplained Behavior/Mutism
6. Psychoses/Hallucinations/Delusions
7. Alcohol Abuse/Detoxification
8. Addiction/Drug Abuse/Withdrawal/Intoxication
9. Assaultive/Threatening Behavior
10. Coping Problem
11. Family Problem
12. Child Abuse/Geriatric Abuse
13. Diagnosis (suspected psychological component)
14. Eating Disorder
15. Ethical Issue/Medical-Legal Issue
16. Interpersonal/Relationship Problem
17. Grief
18. Judgment/Informed Consent/Competency/Discharge AMA
19. Noncompliance/Refusal of Treatment
20. Request to Terminate Care/Euthanasia
21. Confusion/Disorientation/Delirium
22. Patient Request Consult
23. Postpartum/Perinatal Changes
24. Preoperative Assessment
25. Transfer to Psychiatry Assessment
26. Past Psychiatric History Assessment
27. Psychotropic Medication Assessment
28. Medication Induced Disturbance/Drug-Drug Interaction
29. Sexual Problems/Sexual Assault
30. Sleep Disorder
31. Pain Evaluation or Management
32. Constant Observation/Use of Restraints
33. Staff Conflict/Staff-Patient Conflict
34. Paranoid Behavior/Complaints of Abuse
35. Social/School/Work Problem (with psychological component)
36. Hypochondriasis/Excessive or Unusual Physical Complaints
37. Screening of High Risk Medical Procedures (e.g., transplant)
38. Evaluation of Terminally Ill or Dying Patient
39. Malingering/Factitious Disorder (with or without proxy)

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