Billing and Coding: Psychiatric Partial Hospitalization Programs

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34196-Psychiatric Partial Hospitalization
Programs.



**General Guidelines for Claims submitted to Part A or Part B MAC:**

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.



**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)



The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this LCD. (See "Indications
and Limitations of Coverage.") 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.

(42 CFR 424.24)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_ TM 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.  
  

**__Reporting of Service Units:__ **

Hospitals report the number of times the service or procedure, as defined by
the HCPCS code, was performed. CAHs report the number of times the revenue
code visit was performed (CMS Publication 100-04, _Medicare Claims Processing
Manual_ , Chapter 4, Section 260.1[D]).  
  
Claims submitted by either CMHCs or hospital outpatient departments for
partial hospitalization services must include _a mental health diagnosis, and
at least three partial hospitalization HCPCS codes for each day of service,
one of which must be a psychotherapy HCPCS code (other than brief). Claims
that do not pass the_ [Outpatient Code Editor] _OCE edits will undergo further
prepayment review._ (65 FR 18454, April 7, 2000)  
  
 _Repetitive Part B services to a single individual from providers that bill
FIs shall be billed monthly (or at the conclusion of treatment)...Examples of
repetitive Part B services with applicable revenue codes
include...Psychological Services, 0900... 0911-0919 (in a psychiatric
facility)_ (CMS Publication 100-04, _Medicare Claims Processing Manual_ ,
Chapter 1, Section 50.2.2, Rev. 270, Issued 08/03/04, Effective 01/01/05).



**Partial hospitalization services provided by community mental health centers
(CMHCs):  
All _italicized_ text below is from CMS Publication 100-04, _Medicare Claims
Processing Manual_ , Chapter 4, Section 260.1.1 unless otherwise specified.  
 _The CMHCs bill for partial hospitalization services on Form CMS-1450 or
electronic equivalent under bill type 76X. ...The acceptable revenue codes are
as follows:_**

_0914_

_Individual Therapy_

**_Revenue Code_**

|

**_Description_**  
  
---|---  
  
_0250_

|

_Drugs and Biologicals_  
  
_043X_

|

_Occupational Therapy_  
  
_0900_



|

Behavioral Health Treatment/Services  
  
_0904_

|

_Activity Therapy_  
  
_0910_



|

_Psychiatric/Psychological Services (dates of service prior to 10/16/2003)_  
  
_0915_

|

_Group Therapy_  
  
_0916_

|

_Family Therapy_  
  
_0918_

|

_Testing_  
  
_0942_

|

_Education Training_  
  
_The CMHCs are also required to report appropriate HCPCS codes as follows:_

**_Revenue Codes_**

|

**_Description_**

|

**_HCPCS Code_**  
  
---|---|---  
  
_043X_

|

_Occupational Therapy (Partial Hospitalization)_

|

_*G0129_  
  
_0900_



|

Behavioral Health Treatment/Services

|

90791 _or_ 90792  
  
_0904_

|

_Activity Therapy (Partial Hospitalization)_

|

_**G0176_  
  
_0910_



|

_Psychiatric General Services (dates of service prior to 10/16/2003)_

|

_90801, 90802, 90899_  
  
_0914_

|

_Individual Psychotherapy_

|

_90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865 or 90880_  
  
_0915_

|

_Group Psychotherapy_

|

_G0410 or G0411_  
  
_0916_

|

_Family Psychotherapy_

|

_90846 or 90847_  
  
_0918_

|

_Psychiatric Testing_

|

_  96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146_  
  
_0942_

|

_Education Training_

|

_***G0177_  
  
**Section 4523 of the Balanced Budget Act (BBA)(P.L. 105-33), requires payment
to be made under a prospective payment system for partial hospitalization
services furnished by a CMHC. CMHCs must:**

  * Report HCPCS codes and modifiers
  * Report line item dates of service; and
  * Report in Form Locator (FL) 46, "Service Units," the number of times a particular service or procedure based on the HCPCS was performed (not the total number of visits for the billing period). (See CMS Publication 100-04, _Medicare Claims Processing Manual_ , Chapter 4, Section 260.1.1[E].)

When reporting service units for HCPCS codes where the definition of the
procedure does not include any reference to time (either minutes, hours or
days), CMHCs should not bill for sessions of less than 45 minutes. (See CMS
Publication 100-04, _Medicare Claims Processing Manual_ , Chapter 4, Section
260.1.1[E].)

**Partial hospitalization services provided by hospital outpatient
departments:  
** All _italicized_ text below is from CMS Publication 100-04, _Medicare
Claims Processing Manual_ , Chapter 4, Section 260.1 unless otherwise
specified.  
_Hospitals and CAHs report condition code 41 in FLs 18-28 (or electronic
equivalent) to indicate the claim is for partial hospitalization services.
They must also report a revenue code and the charge for each individual
covered service furnished. In addition, hospital outpatient departments are
required to report HCPCS codes. CAHs are not required to HCPCS code for this
benefit_ (CMS Publication 100-04, _Medicare Claims Processing Manual_ ,
Chapter 4, Section 260.1[A]).  
 _Under component billing, hospitals are required to report a revenue code and
the charge for each individual covered service furnished under a partial
hospitalization program. In addition, hospital outpatient departments_ [other
than CAHs] _are required to report HCPCS codes. Component billing assures that
only those partial hospitalization services covered under Section 1861(ff) of
the Act are paid by the Medicare program_ (CMS Publication 100-04, _Medicare
Claims Processing Manual_ , Chapter 4, Section 260.1[A]).  
_All hospitals are required to report condition code 41 in FLs 18-28 to
indicate the claim is for partial hospitalization services. Hospitals use bill
type 13X and CAHs use bill type 85X. The following special procedures apply.  
Bills must contain an acceptable revenue code. They are as follows:_

**_Revenue Code_**

|

**_Description_**  
  
---|---  
  
_0250_

|

_Drugs and Biologicals_  
  
_043X_

|

_Occupational Therapy_  
  
_0900_



|

Behavioral Health Treatment/Services  
  
_0904_

|

_Activity Therapy_  
  
_0910_



|

_Psychiatric/Psychological Services (dates of service prior to 10/16/2003)_  
  
_0914_

|

_Individual Therapy_  
  
_0915_

|

_Group Therapy_  
  
_0916_

|

_Family Therapy_  
  
_0918_

|

_Testing_  
  
_0942_

|

_Education Training_  
  
_Hospitals other than CAHs are also required to report appropriate HCPCS codes
as follows:_

**_Revenue Code_**

|

**_Description_**

|

**_HCPCS Code_**  
  
---|---|---  
  
_043X_

|

_Occupational Therapy_

|

_*G0129_  
  
_0900_



|

Behavioral Health Treatment/Services

|

_90791 or 90792_  
  
_0904_

|

_Activity Therapy (Partial Hospitalization)_

|

_**G0176_  
  
_0910_



|

_Psychiatric General Services (dates of service prior to 10/16/2003)_

|

_90801, 90802, 90899_  
  
_0914_

|

_Individual Psychotherapy_

|

_90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865, or 90880_  
  
_0915_

|

_Group Therapy_

|

_G0410 or G0411_  
  
_0916_

|

_Family Psychotherapy_

|

_90846 or 90847_  
  
_0918_

|

_Psychiatric Testing_

|

_  96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146_  
  
_0942_

|

_Education Training_

|

_***G0177_  
  
Under component billing, Critical Access Hospitals (CAHs) are required to
report an acceptable revenue code, in accordance with those listed above, and
the charge for each individual covered service furnished under a partial
hospitalization program.  
  
 _Hospitals and Community Mental Health Centers (CMHCs) are required to report
all OPPS services that are provided on the same day on the same claim with the
exception of claims containing condition codes 20, 21, or G0 (zero) or
containing repetitive Part B services. If an individual OPPS service is
provided on the same day as an OPPS repetitive service, the individual OPPS
service must be billed separately, with all related services, from the OPPS
monthly repetitive claim. However, if some of the services are for partial
hospitalization, the provider shall place condition code 41 on the claim. For
claims containing condition code 41, all services billed on the same day are
to be included on the monthly bill for repetitive services. Non-repetitive
OPPS services, exclusive of partial hospitalization services, are to be put on
a single claim along with any packaged services. Repetitive services are
billed monthly on a separate claim_ (CMS Publication 100-04, _Medicare Claims
Processing Manual_ , Chapter 4, Section 170, Rev. 239, Issued 07/23/04,
Effective 01/01/05).



**Other Comments:  
  
** For claims submitted to the Part A MAC: this coverage determination also
applies within states outside the primary geographic jurisdiction with
facilities that have nominated CGS Administrators to process their claims.  
  
Bill type codes only apply to providers who bill these services to the Part A
MAC. Bill type codes do not apply to physicians, other professionals and
suppliers who bill these services to the carrier or Part B MAC.  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.  
  
If the facility portion of partial hospitalization programs is denied as not
medically necessary this does not mean that the physician service is also not
medically necessary. The physician service to the patient may be medically
necessary even though the level of service rendered in a partial
hospitalization facility is not medically necessary.  
  
For outpatient settings other than CORFs, references to "physicians"
throughout this policy include non-physicians, such as nurse practitioners,
clinical nurse specialists and physician assistants. Such non-physician
practitioners, with certain exceptions, may certify, order and establish the
plan of care as authorized by State law. (See Sections 1861(s)(2) and
1862(a)(14) of Title XVIII of the Social Security Act; 42 CFR, Sections
410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)