Facility Based Crisis Services

Description of Procedure or Service

Facility-Based Crisis Service is a service that provides an alternative to hospitalization for an individual who presents with escalated behavior due to a mental health, intellectual or development disability or substance use disorder and requires treatment in a 24-hour residential facility. Facility-Based Crisis Service is a direct and indirect, intensive short term, medically supervised service provided in a physically secure setting, that is available 24 hours a day, seven days a week, 365 days a year.

Under the direction of a psychiatrist, this service provides assessment and short-term therapeutic. interventions designed to prevent hospitalization by de-escalating and stabilizing acute responses to crisis situations.

The Facility-Based Crisis Service includes professionals with expertise in assessing and treating mental health and substance use disorders and intellectual or developmental disabilities. The service must address the age, behavior, and developmental functioning of each individual to ensure safety, health, and appropriate treatment interventions.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and / or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for Facility Based Crisis Services when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy.

When Facility Based Crisis Services are covered

Facility Based Crisis Services are considered medically necessary for one or more of the following:

Admission to Crisis Intervention Level of Care may be considered medically necessary when ALL the following criteria is met:

• Around-the-clock behavioral care or close monitoring and intervention is indicated by 1 or more of the following:
  • Danger to self for adult, child, or adolescent
  • Danger to others for adult, child, or adolescent
  • Serious dysfunction in daily living for adult, child, or adolescent
• Patient management / treatment at lower level of care is not feasible (e.g., lower level of care is unavailable or is not appropriate for patient condition) until acute intervention or modification (e.g., acute medication, identification of needed resources and support, change in living situation) is initiated. 
• Situation and expectations are appropriate for crisis intervention services, as indicated by ALL of the following:
  • Recommended treatment is necessary, appropriate, and not feasible at lower level of care (e.g., lower level of care is inappropriate for patient condition or is not available).
  • Sufficient treatment outcome (e.g., stabilization and identification of resources and support for care outside of crisis intervention services) is expected within short time period (e.g., 1 to 3 days).
  • Patient is willing to participate in treatment (or agrees to participate at direction of parent or guardian) within specified intervention and treatment structure voluntarily (or due to court order).
  • There is no anticipated need for physical restraint, seclusion, or other involuntary control (e.g., patient not actively violent).
  • There is no need for around-the-clock medical or nursing care.
  • Patient has sufficient ability to respond as planned to individual and group therapeutic interventions.
  • Biopsychosocial stressors potentially contributing to clinical presentation (e.g., comorbidities, illness history, environment, social network, ability to cope, and level of engagement) have been assessed and are absent or manageable at proposed level of care.

Continued crisis care for Adults, Child, or Adolescent is considered medically necessary when the initial approval criteria continue to be met.

When Facility Based Crisis Services are not covered

Facility Based Crisis Services are considered not medically necessary for one or more of the following:

Facility Based Crisis Services are considered not medically necessary when the criteria above is not met.

Crisis care is no longer indicated due to one or more of the following:

• Higher level of care is indicated (e.g., individual condition has deteriorated, greater service intensity is necessary to support engagement in care or reinforce skills, or more intensive supervision is necessary to address clinical needs).
• Patient or guardian refuses treatment

Continued crisis care for Adults, Child, or Adolescent is considered not medically necessary for one or more of the following:

• Crisis care is no longer necessary due to adequate individual stabilization or improvement, as indicated by ALL the following:
  • Acceptable risk status, as indicated by ALL the following
    • Danger to self or others manageable / treatable, as indicated by one of the following:
      • Absence of suicidal or homicidal thoughts, or thoughts of serious harm to self or to another
      • Suicidal or homicidal thoughts, or thoughts of serious harm to self or to another are present but manageable / treatable at available lower level of care.
      • Individual and supports understand follow-up treatment and crisis plan.
      • Provider and supports are sufficiently available at lower level of care.
      • Individual, as appropriate, can participate as needed in monitoring at available lower level of care.
• Acceptable functional status, as indicated by one or more of the following:
  • No essential function is significantly impaired.
  • An essential function is impaired, but impairment is manageable / treatable at available lower level of care.
• Medical needs absent or manageable / treatable at available lower level of care, as indicated by ALL the following
  • Adverse medication effects absent or manageable / treatable
  • Medical comorbidity absent or manageable / treatable
  • Medical complications absent or manageable / treatable (e.g., complications of eating disorder)
  • Substance-related disorder absent or manageable / treatable
• Treatment plan for follow-up care and safety monitoring (e.g., safety plan) completed.

Policy Guidelines

Facility Based Crisis Services requires precertification, prior plan approval, or prior authorization.

The purpose of the care guidelines is to promote evidence-based care across the continuum of care to enhance the delivery of quality healthcare. Indications are presented for different levels of care. These indications help define the optimal level of care and can assist in developing alternatives to higher levels of care, tracking individual progress during treatment within a level of care, facilitating the progress of individuals whose recovery is delayed, and preparing comprehensive plans for transition of patients from one level of care to another. Relevant professional society guidelines are foundational content for evaluation and treatment of behavioral health disorders at different levels of care and are complemented by the best available published evidence

Billing / Coding / Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: S9484

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and / or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

Level of care placement. In: Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, Provence SM, editors. ASAM Criteria Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013:174-306.

PA Work Group on Psychiatric Evaluation. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd edition [Internet] American Psychiatric Association. 2016 Accessed at: https://psychiatryonline.org/.

Sudak HS. Suicide treatment. In: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2017:2618-2622

Fenton WS, Hoch JS, Herrell JM, Mosher L, Dixon L. Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness. Archives of General Psychiatry 2002;59(4):357-64

Berrino A, Ohlendorf P, Duriaux S, Burnand Y, Lorillard S, Andreoli A. Crisis intervention at the general hospital: an appropriate treatment choice for acutely suicidal borderline patients. Psychiatry Research 2011;186(2-3):287-92. DOI: 10.1016/j.psychres.2010.06.018

Cotton MA, et al. An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams. BMC Psychiatry 2007; 7:52. DOI: 10.1186/1471-244X-7-52.

Adams CL, El-Mallakh RS. Patient outcome after treatment in a community-based crisis stabilization unit. Journal of Behavioral Health Services & Research 2009;36(3):396-9. DOI: 10.1007/s11414-008-9141-3.

Howard LM, Rigon E, Cole L, Lawlor C, Johnson S. Admission to women's crisis houses or to psychiatric wards: women's pathways to admission. Psychiatric Services 2008;59(12):1443-9. DOI: 10.1176/appi.ps.59.12.144

American Association of Community Psychiatrists. Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS). Adult version 20 [Internet] American Association of Community Psychiatrists. 2016 Dec Accessed at: https://www.communitypsychiatry.org/keystone-programs/locus.

American Association of Community Psychiatrists. CALOCUS/CASII: Child and Adolescent Level of Care Utilization System. Child and Adolescent Version 20 [Internet] American Association of Community Psychiatrists. 2019 Jul Accessed at: https://www.communitypsychiatry.org/resources/locus.

Level of care placement. In: Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, Provence SM, editors. ASAM Criteria Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013:174-306.

APA Work Group on Psychiatric Evaluation. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd edition [Internet] American Psychiatric Association. 2016 Accessed at: https://psychiatryonline.org/.

Medical Director Review 9/2024

Policy Implementation / Update Information

10/1/24 New policy developed. Facility Based Crisis Services are considered medically necessary when the criteria above are met. Medical Director review 9/2024. Notification given 10/1/2024 for effective date 12/31/2024. (tt)