by Wyn Staheli, Director of Content - innoviHealth
Jan 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of care. According to the Medicare Benefit Policy Manual Chapter 6, Section 70.3 these would also be patients who are at a reasonable risk of requiring inpatient hospitalization.
Psychiatric Partial Hospitalization is a distinct and organized intensive psychiatric treatment of less than 24 hours of daily care, designed to provide patients with profound or disabling mental health conditions in an individualized, coordinated, intensive, comprehensive, and multidisciplinary treatment program not provided in a regular outpatient setting.
It should be noted that there are differences between the billing and guideline requirements for Psychiatric PHPs and Substance Abuse PHPs. It is essential for providers to understand that these billing requirements and guidelines are not standardized for all payers which leaves it up to the provider to obtain this information from the payer prior to rendering services. The information presented here provides some general understanding, but does NOT supercede payer policies.
While admission criteria can vary, the following information from one Medicare Administrative Contractor (MAC) provides some useful guidelines:
One of the following criteria must be met (CMS Benefit Policy Manual, Chapter 6, Section 70.3; CMS PHP LCDs, 2017):
- The patient is being discharged from an inpatient hospital setting and PHP services are to be provided in lieu of continued inpatient treatment; or
- In the absence of PHP, the patient would be at reasonable risk of requiring inpatient hospitalization
All of the following criteria must be met (CMS Benefit Policy Manual, Chapter 6, Section 70.3; CMS PHP LCDs, 2017):
- The patient is under the care of a physician who certifies the need for the intensive, structured combination of active treatment services provided by a PHP.
- The patient does not require 24-hour per day level of care provided in an inpatient setting.
- The patient has an adequate support system to sustain/maintain him/herself outside of the PHP.
- The patient is not in imminent danger to him/herself or others, although there may be recent history of selfmutilation, serious risk taking, or other self-endangering behavior.
- In general, patients should be treated in the least intensive and restrictive setting which meets the needs of their illness. In order to be admitted to a PHP program there must be evidence of an inability to benefit from a less intensive outpatient program.
- The patient requires a minimum of 20 hours per week of active treatment, as evidenced by an acute onset or decompensation of a mental disorder which severely and acutely interferes with multiple areas of daily life including social, vocational, and/or educational functioning.
- There is a reasonable expectation of improvement of the patient’s condition and level of functioning as a result of active PHP treatment.
- The patient is able to cognitively and emotionally participate in the active treatment process, and be capable of tolerating the intensity of services provided by the PHP program.
- The degree of functional impairment is severe enough to require a multidisciplinary, intensive, structured program, but not so limiting that the patient cannot benefit from participating in an active treatment program.
- The patient requires PHP services at levels of intensity and frequency comparable to patients in an inpatient setting for similar psychiatric illnesses (CMS LCD L34196, 2017).
- The patient’s Global Assessment of Function is below 40 according to the DSM-IV-TR (CMS LCD L34196, 2017).
When payers have guidelines such as this, it is imperative that documentation includes ALL this pertinent information (e.g., support system, functional impairment level) in an easy to find format.
The following table summarizes information from different payer policies so code requirements could vary from what is presented here:
Service Type Type of Bill Revenue Code HCPCS Code & Description Substance abuse 131 0912 S9475 - Ambulatory setting substance abuse treatment or detoxification services, per diem Other psychiatric 131 0912 or 0913 H0035 - Mental health partial hospitalization, treatment, less than 24 hours
Medicare handles PHP differently than other payers. Guidelines are found in the Medicare Claims Processing Manual, Chapter 4, Section 260.1. Note that PHP can be provided in Hospitals, Community Mental Health Centers (CMHCs), and Critical Access Hospitals (CAHs). Just be sure to use the appropriate Type of Bill codes. Medicare wants Hospitals and CMHCs (but not CAHs) to also include appropriate HCPCS codes. The following table summarizes billing information as described in the Claims Processing Manual:
Revenue Code (RC) & Description CPT/HCPCS Code Notes 0250 Drugs and Biologicals Does not require CPT/HCPCS coding. Medicare does not cover drugs that can be self-administered 043X Occupational Therapy G0129 This code is only for PHPs 0900 Behavioral Health Treatment/Services 90791 or 90792 Some payers allow 90785 to be billed with this RC 0904 Activity Therapy G0176 Used only for PHPs 0914 Individual Therapy 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865, or 90880 0915 Group Therapy G0410 or G0411 1. Some provider services may be billed separately. Coverage for these are determined by the local MAC.
2. Other payers accept 90853 with this RC
0916 Family Therapy 90846 or 90847 Other payers could also accept 90849 with this RC 0918 Testing 96101, 96102, 96103, 96116, 96118, 96119, or 96120 0942 Education Training G0177 May be used in both PHP and outpatient mental health settings
Note: Part B deductibles and co-insurance would apply.
CMS Coverage Guidelines
According to CMS’s Medicare Benefit Policy Manual, Chapter 6, Section 70.1; in order to be eligible for reimbursement, the following is required:
- Individualized Treatment Plan: “The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals.”
- Physician Supervision and Evaluation: “Services must be supervised and periodically evaluated by a physician to determine the extent to which treatment goals are being realized.” This includes consultation and conference with therapists and staff, review of medical records, and patient interviews. Documentation needs to indicate that the treatment plan has been evaluated and revised as necessary to meet treatment goals.
- Reasonable Expectation of Improvement: “Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning.”
Other Coding Information
The following coding information is from Medicare so other payer policies may differ:
- Use Condition Code 41 for hospitals and CAHs.
- Type of Bill
- Hospitals use 13X
- CMHC use 76X
- CAH use 85X
- APCs: CMHCs use 5853 and hospitals use 5863
- The “Dates of Service” field cannot span more than one date. Each service date must be on it’s own line. See their example found in Section 260.1.1.F.
For more information about Medicare’s coverage see the following:
- Medicare Benefit Policy Manual Chapter 6
- MLN Matters® Number: SE1604
- Noridian’s Hospital-based PHP Billing Guide
- Optum’s PHP Coverage Summary
REVENUE CODES (RC)
All payers require the claim to be submitted with the appropriate revenue code that describes the service provided. For other payers, the same revenue codes seem to be used for PHP services. The following table shows some additional RC options which potentially could be used for non-Medicare PHP claims:
- 0900 General Classification
- 0901 Electroshock Treatment
- 0912 Partial Hospitalization* - Less Intensive
- 0913 Partial Hospitalization* - Intensive
- 0944 Drug Rehabilitation
- 0945 Alcohol Rehabilitation
What is included also varies by payer. Many include professional services in the per diem rate, but most have exceptions. The following quotes from a few payers demonstrates those differences and the need to verify coverage for individual payers.
Professional services may be considered inclusive to the inpatient stay or “Separately, to the professional billing for the provided services if they are recognized under part B and considered separate from the inpatient stay (for instance, physicians, and NPPs within their state scopes of practice).” - CMS- MLN #SE1606
Blue Cross/Blue Shield of North Dakota:
Psychiatrists and psychologists may bill separately on the CMS-1500 for services outside of the treatment program that are medically appropriate and necessary, such as psychological testing, individual therapy for psychiatric diagnoses and E&M services. Group or family counseling cannot be billed in addition to the partial hospitalization stay.
Electroshock Therapy is often reported separately with RC 901 and code 90870. The Medicare Claims Processing Manual, Chapter 4, Section 170 states:
When a hospital provides electroconvulsive therapy (ECT) on the same day as partial hospitalization services, both the ECT and partial hospitalization services should be reported on the same hospital claim. In this instance, the claim should contain condition code 41. As noted above, report charges for all services and supplies associated with the ECT service, which were furnished on the same date(s) on the same claim.
Group Tobacco Cessation may be reported separately for some payers, in which case, it would be reported with RC 953 and code 99412.
Medication Management (RC 919 and codes 99201-99205, 99211-99215) is typically not covered according to the policies we reviewed as most consider it inclusive to the PHP service and thus not separately payable.
Medicare Excluded Services
The following are specifically excluded from coverage by Medicare:
- Day care programs, which provide primarily social; recreational or diversionary activities; custodial or respite care
- Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill
- Patients who are otherwise psychiatrically stable or require medication management only
- Self-administered medications
- Vocational training (e.g., career)
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.