Billing and Coding: Psychiatric Partial Hospitalization Programs

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Psychiatric Partial Hospitalization Programs.

National Coverage Provisions:

Professional Services Related to Psychiatric Partial Hospitalization:

Note: The following billing requirements also apply to CMHC providers. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 260.1 [B].)
The professional services listed below when provided in all hospital outpatient departments are separately covered and paid as the professional services of physicians and other practitioners. These professional services are unbundled and these practitioners bill the Medicare Part B carrier directly for the professional services furnished to hospital outpatient partial hospitalization patients. The hospital can also serve as a billing agent for these professionals by billing the Part B carrier on their behalf under their billing number for their professional services. The following direct professional services are unbundled and not paid as partial hospitalization services:

• Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;

• Physician assistant (PA) services as defined in §1861(s)(2)(K)(i) of the Act;

• Nurse practitioner and clinical nurse specialist services, as defined in §1861(s)(2)(K)(ii) of the Act; and

• Clinical psychologist services as defined in §1861(ii) of the Act.

The services of other practitioners (including clinical social workers and occupational therapists), are bundled when furnished to hospital patients, including partial hospitalization patients. The hospital must bill the contractor for such nonphysician practitioner services as partial hospitalization services. [P] ayment for the services [is made] to the hospital.

See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 260.1.1[C] for billing requirements for CMHCs.

Patients admitted to a partial hospitalization program must require a minimum of 20 hours per week of therapeutic services, as evidenced by their plan of care.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentations Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage." in LCD) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Upon admission, a certification by the physician (MD/DO) must be made that the patient admitted to the partial hospitalization program would require inpatient psychiatric hospitalization if the partial hospitalization services were not provided and must include an attestation that the services are furnished while the individual is under the care of a physician, and that the services are furnished under an individualized written plan of care.

Recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. The first recertification is required as of the 18 th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days [i.e., no less frequently than every 30 days following the first recertification which must be made as of the 18 th day of partial hospitalization services]. The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following:

• The patient's response to the therapeutic interventions provided by the partial hospitalization program.
• The patient's psychiatric symptoms that continue to place the patient at risk of hospitalization.
• Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program.

The initial psychiatric evaluation with medical history and physical examination must be performed and placed in the chart within 48 hours of admission in order to establish medical necessity for partial hospitalization services. If the patient is being discharged from an inpatient psychiatric admission to a partial hospitalization program, the psychiatric evaluation, medical history, and physical examination from that admission with appropriate update is acceptable. In order to support the medical necessity of admission to the partial hospitalization program, the documentation in the initial psychiatric evaluation should include the following items:

• Patient's chief complaint;
• Description of acute illness or exacerbation of chronic illness requiring admission;
• Current medical history, including medications and evidence of failure at or inability to benefit from a less intensive outpatient program;
• Past psychiatric and medical history;
• History of substance abuse;
• Family, vocational and social history, including documentation of an adequate support system to sustain/maintain the patient outside the partial hospitalization program;
• Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self harm and harm to others, insight, judgment, capacity for activities of daily living (ADLs);
• Physical examination (if not done within the past 30 days and available for inclusion in the medical record);
• Formulation of the patient's status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the partial hospitalization program;
• ICD-10-CM/DSM-IV-TR™ diagnoses, including all five axes of the multiaxial assessment as described in the DSM-IV-TR;
• Treatment plan, including long and short term goals related to the active treatment of the reason for admission, and types, amount, duration, and frequency of therapy services, including activity therapy, required to address the goals.

A team approach may be used in developing the initial psychiatric evaluation, but the physician (MD/DO) must document the mental status examination, physical examination, formulation, diagnosis, treatment plan, and certification.

Partial hospitalization is active treatment that incorporates an individualized treatment plan, which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care. The treatment plan is established by the physician, in consultation with appropriate staff members, and should be reviewed according to the changing needs of the patient's acute psychiatric illness, but never less than every 31 days. The treatment plan should be reviewed more frequently if the severity of the clinical condition or changes in the clinical condition of the patient (e.g., change of medication) make it reasonable to do so. The long and short-term treatment goals described in the treatment plan are the basis for evaluating the patient's response to treatment. Treatment goals should be designed to measure the response to treatment, for this relationship will be used in determining whether services are medically necessary. The treatment goals should be measurable, functional, time-framed, and directly related to the reason for admission. The treatment plan must include the specific treatments ordered, including reference to psychotropic medication management, the expected timeframes and outcomes for each treatment, and the discharge plan.

Section 1833(e) of the Social Security Act requires services to be documented in order for payment to be made. Therefore, a separate progress note is required for each service rendered (e.g., HCPCS or revenue code billed). The progress note should be written by the team member rendering the service and should include a description of the nature of the treatment service, the patient's status (behavior, verbalizations, mental status) during the course of the service, the patient's response to the therapeutic intervention and its relation to the long or short term goals in the treatment plan. Each progress note should be legible, dated and signed, and include the credentials of the rendering provider. Documentation of group therapy sessions must indicate the name of the group, group type, an indication of the material under discussion, and the patient's response to the treatment encounter.