Geropsychiatric Nursing Facility Services (Clinical Coverage Policy 2B-2)
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Medicaid coverage and requirements for geropsychiatric units in North Carolina nursing facilities, defining eligibility, clinical criteria, staffing/training, and service provisions for beneficiaries (primarily aged 65+) with severe and persistent mental illness (SPMI).
Removed continued stay geropsychiatric unit criteria requirement to comply with federal parity and CFR § 438.900.
Coverage and Medical Necessity Criteria
inv-01: Medicaid Additional Coverage Criteria for Geropsychiatric Units
Covered when ALL of the following are met
From general criteria covered
General and financial eligibility requirements
Must document DSM diagnosis
Pre-admission requirement
PASRR compliance required
Any one of these qualifies
Any listed behavior supports need for geropsychiatric unit
Document lack of appropriate alternatives
inv-02: Medicaid Additional Criteria - Covered Admissions
Covered when ALL of the following are met
Exact behaviors and PASRR requirements per policy subsections 3.2.2 c–e
inv-03: Discharge Criteria
Discharge contingent upon ALL of the following
Trial stays on a regular nursing unit required to demonstrate anticipated stability
inv-04: Facility and Staffing Requirements
Facility/service coverage requires meeting enhanced staffing and therapeutic environment provisions
Shift ratios specified in policy (first/second/third shift CNA and LPN ratios, RN hours)
inv-05: Staff Training
Staff training requirements
Training per 10A NCAC 27E.0107 and MH/DD/SAS curriculum
inv-06: Coverage Conditions for Geropsychiatric Unit Services
Covered when facility operates a geropsychiatric specialty unit that meets statutory and program requirements and documents required staff training and reporting.
See MH/DD/SAS training guidelines referenced in policy
Per reporting requirements for geropsychiatric specialty units
See attachments and billing sections for coding instructions; billing type: Institutional (UB-04/837I)
Subsection 3.2.1 Specific criteria covered by Medicaid: None apply.
Medicaid will not cover services when the beneficiary fails to meet the eligibility requirements in Section 2.0, fails to meet the coverage/medical necessity criteria in Section 3.0, when the service duplicates another provider's procedure or product, or when the service is experimental, investigational, or part of a clinical trial.
The policy was revised effective 01/01/2025 to comply with federal parity requirements (Mental Health Parity and Addiction Equity Act and 42 CFR § 438.900). As a result, the previous continued-stay criteria specific to geropsychiatric units were removed; there are no continued-stay criteria for the geropsychiatric unit in this policy.
Services are not covered for beneficiaries who are not enrolled in NC Medicaid, who do not meet Medicaid financial or nursing facility level-of-care eligibility, or who have service restrictions tied to their eligibility category; providers must verify Medicaid eligibility each time a service is rendered.
Services are not covered when the coverage or medical necessity criteria in Sections 2.0 and 3.0 are not met.
Billing, Codes, and Claim Rules
| ICD-10 codes | Refer to Attachment A: International Classification of Diseases and Related Health Problems, Tenth Revisions (specific codes listed in Attachment A) |
| Modifiers | Refer to Attachment A for applicable modifiers |
| Institutional (UB-04/837I) | Claim type required for institutional billing |
| ICD-10-CM/PCS | Report to highest level of specificity; use current edition |
| CPT | Use current CPT for procedure coding; if unlisted, follow CPT unlisted procedure reporting and special report |
| HCPCS | Use current HCPCS; if unlisted, follow HCPCS unlisted procedure reporting and special report |
| Revenue codes | Use UB-04 Data Specifications Manual for valid revenue codes |
| Modifiers | Follow applicable modifier guidelines |
Provider Requirements, Prior Authorization, and Documentation
Refer to Nursing Facility Services Policy
Refer to Clinical Coverage Policy 2B-1, Nursing Facility Services, for detailed service requirements, certification, and prior authorization rules that apply to nursing facility admissions and geropsychiatric units.
- See: Clinical Coverage Policy 2B-1 for PASRR guidance and nursing facility level-of-care determinations.
Eligibility Verification and Financial Determination
Providers must verify each beneficiary's Medicaid enrollment and any financial eligibility or service restrictions before admission. The local department of social services determines financial eligibility; the designated state contractor determines medical necessity.
- Verify Medicaid eligibility at the time of service.
- Confirm financial eligibility with the local department of social services.
- Confirm medical necessity and level-of-care determinations with the designated state contractor.
General Denial Triggers
Claims or admissions may be denied if beneficiaries do not meet eligibility or coverage criteria, or if services duplicate others or are experimental/investigational.
- Denial triggers include: failure to meet Section 2.0 (eligibility) or Section 3.0 (coverage) criteria.
- Claims for services that duplicate another provider's service may be denied.
- Services that are experimental, investigational, or part of a clinical trial are not covered.
Billing and Coding Denial Risks
Bill institutional claims on UB-04/837I (Institutional). Use National Uniform Billing Guidelines and report ICD-10-CM/PCS and CPT/HCPCS to the highest level of specificity that supports medical necessity.
- Submit Institutional (UB-04/837I) claims unless directed otherwise.
- Use National Uniform Billing Guidelines and National Coding Guidelines.
- Report ICD-10-CM/PCS and CPT/HCPCS codes to the highest level of specificity.
- If no specific CPT/HCPCS code exists, use the appropriate unlisted procedure/service code.
Clinical Documentation for SPMI Eligibility
Documentation must support an SPMI diagnosis and related criteria for geropsychiatric placement, including a DSM-diagnosable major mental disorder and a pre-admission GAF score of 40 or lower; a Level II PASRR evaluation must confirm SPMI and related needs.
- Document DSM-based SPMI diagnosis (e.g., schizophrenia, bipolar disorder, major depression, schizoaffective disorder, schizophreniform, psychotic disorder NOS).
- Provide pre-admission Global Assessment of Functioning (GAF) score ≤ 40.
- Include Level II PASRR evaluation confirming SPMI and recommendations.
Required Documentation
Prior to seeking reimbursement or admission, providers must confirm beneficiaries meet Sections 2.0 and 3.0 and maintain required clinical and PASRR documentation in the medical record.
- Confirm beneficiary meets Section 2.0 (Eligible Beneficiaries) requirements.
- Confirm beneficiary meets Section 3.0 (When the Service is Covered) requirements.
- Retain PASRR Level II evaluation documentation and all clinical records supporting medical necessity and that alternatives were considered or unavailable.
(No content specified.)
Background and Scope
Geropsychiatric units are specialized nursing facility units that provide skilled nursing care combined with enhanced supervision and behavioral management for geriatric beneficiaries with severe and persistent mental illness (SPMI). Coverage requires that the service be individualized, specific, consistent with the beneficiary's confirmed diagnosis and needs, safely provided, and not primarily for convenience. The unit is intended for beneficiaries whose psychiatric and behavioral health needs exceed management capacity of traditional nursing units.
Key Definitions
Admission Criteria for Geropsychiatric Units
inv-38: nursing facility geropsychiatric unit
inv-39: SNF
inv-40: SNF
Continued Stay and Review
inv-41: nursing facility geropsychiatric unit
inv-42: SNF
inv-43: SNF
Discharge Criteria
A nursing facility geropsychiatric unit serves Medicaid beneficiaries who meet nursing facility level-of-care criteria and have an SPMI diagnosis; admissions require documentation of SPMI, a pre-admission GAF ≤ 40, PASRR Level II confirmation, demonstrated behavioral risk or history of psychiatric hospitalization, and documentation that alternative services are unavailable or inappropriate.
For Skilled Nursing Facility (SNF) operation, providers must meet the general medical necessity requirements in Section 3.1, maintain enhanced staffing and therapeutic environment provisions (staffing scaled per a 20‑bed unit), ensure nursing staff complete required behavioral health training (40 initial hours with 20 hours annually thereafter), and comply with PASRR and reporting requirements when operating a geropsychiatric specialty unit.
SNF providers operating an enhanced geropsychiatric unit must comply with staffing, bed-count, and training rules: a 20‑bed unit configuration is the standard option unless expanded with CON approval; required staffing and shift ratios are defined per 20‑bed unit and include psychiatric/psychology FTEs and specified nursing FTEs; nursing staff must complete the mandated behavioral health training curriculum.
Bed Limits and Billing Day Rules
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