(Medicare Claims Processing Manual)

Excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures and/or surgeries provided at off -campus provider -based outpatient departments) for all excepted items and services furnished. Use of the off -campus PBD modifier became mandatory beginning January 1, 2016.    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 October 16, 2003)   0914  Individual Therapy   0915  Group Therapy   0916  Family Therapy   0918  Behavioral Health/Testing   0942  Education/Training    Hospitals other than CAHs are also required to report appropriate HCPCS codes as follows:    Revenue Code  Descripon  HCPCS Code  043X  Occupaonal Therapy  *G0129 ( PHP/IOP )  0900  Behavioral Health  Treatment/Services  ****90791 or ***** 90792 , 97153, 97154, 97155, 97156, 97157, 97158   0904  Acvity Therapy   **G0176 ( PHP/IOP )  0914  Individual Psychotherapy  90785, 90832, 90833, 90834,  90836, 90837, 90838, 90839, 90840,  90845, 90880, 90899    0915  Group Therapy  G0410 , G0411, 90853   0916  Family Psychotherapy  90846 , 90847 , 90849  0918   Behavioral Health/Tesng  96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138 ,  96139, 96146, 96156, 96158, 96161, 96164, 96167, 97151, 97152   0942  Educaon/Training  G0023, G0024, G0140, G0146, ***G0177 , G0451, 96202, 96203, 97550, 97551, 97552     The A/B MAC (A) will edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  The A/B MAC (A) will not edit for matching the revenue code to HCPCS.    *The definition of code G0129 is as follows:    Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization or intensive outpatient treatment program, per session (45 minutes or more).    **The definition of code G0176 is as follows:    Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patients disabling mental problems, per session (45 minutes or more).    ***The definition of code G0177 is as follows:    Training and educational services related to the care and treatment of patients disabling mental health problems, per session (45 minutes or more).    ****The definition of code 90791 is as follows:    Psychiatric diagnostic evaluation (no medical services) completed by a non -physician.    *****The definition of code 90792 is as follows:    Psychiatric diagnostic evaluation (with medical services) completed by a physician.    Codes G0129 and G0176 are used only for intensive outpatient programs or  partial hospitalization programs.    Code G0177 may be used in intensive outpatient programs, partial hospitalization programs , and outpatient mental health settings.    Revenue code 0250 does not require HCPCS coding.  However, Medicare does not cover drugs that can be self -administered.    Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  Do not edit for the matching of revenue code to HCPCS.    B. Professional Services     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 (other than physician assistants (PA) bil l the Medicare A/B MAC (B) 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 A/B MAC (B) on their behalf under their billing number for their professional services.  The professional services of a PA can be billed to the A/B MAC (B) only by the PA 's employer.  The employer of a PA may be such entities or individuals as a physician, medical group, professional corporation, hospital, SNF, or nursing facility.  For example, if a physician is the employer of the PA and the PA renders services in the hos pital, the physician and not the hospital would be responsible for billing the A/B MAC (B) on Form CMS -1500 for the servi ces of the PA.  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 , marriage and family therapists, mental health counselors, 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.  Make payment  for the services to the hospital.    C. Outpatient Mental Health Treatment Limitation     The outpatient mental health treatment limitation may apply to services to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CNSs, and PAs to partial hospitalization patients.  However, the outpatient mental health treatment limitation does not  apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC or hospital outpatient department as partial hospitalization services.    D. 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.    NOTE : Service units are not required to be reported for drugs and biologicals (Revenue Code 0250).    E. Line Item Date of Service Reporting     Hospitals other than CAHs are required to report line item dates of service per revenue code line for partial hospitalization claims.  This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the  service was provided for every occurrence.  Line item dates of service are reported in FL 45 Service Date (MMDDYY).  See 260.5 for a detailed explanation.    F. Payment    Starting in CY 2024 and subsequent years, the payment structure for partial hospitalization services provided in hospital outpatient departments and CMHCs has been set to four (4) separate  APCs: Community Mental Health Center PHP APCs 5853 (Level 1 Partial Hospitalization Program (up to 3 services)) and 5854 (Level 2 Partial Hospitalization Program (4 or more services)) and Hospital -based PHP APCs 5863 (Level 1 Partial Hospitalization Program (up to 3 services)) and 5864 (Level 2 Partial Hospitalization Pro gram (4 or more services)).  The following chart displays the CMHC and hospital -based PHP APCs:    Hospital -Based and Community Mental Health Center PHP APCs    CY 2024  APC  Group Title  5853  Paral Hospitalizaon (3 or fewer  services per day) for CMHCs   5854  Partial Hospitalization (4 or more services per day) for CMHCs  5863  Paral Hospitalizaon (3 or fewer  services per day) for hospital-based PHPs  5864  Partial Hospitalization (4 or more services per day) for hospital -based PHPs     Apply Part B deductible, if any, and coinsurance.    G. Data for CWF and PS&R     Include revenue codes, HCPCS/CPT codes, units, and covered charges in the financial data section (fields 65a -  65j), as appropriate.  Report the billed charges in field 65h, "Charges," of the CWF record.    Include in the financial data portion of the PS&R UNIBILL, revenue codes, HCPCS/CPT codes, units, and charges, as appropriate.    Future updates will be issued in a Recurring Update Notification.   260.1.1 - Bill Review for Partial Hospitalization Services Provided in Community Mental Health Centers (CMHC)  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    A. General    Medicare Part B coverage for partial hospitalization services provided by CMHCs is available effective for services provided on or after October 1, 1991.    B. Special Requirements    Section  1866(e)(2) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act recognizes CMHCs as providers of services but only for furnishing partial hospitalization or intensive outpatient  services.  Applicable provider ranges are 1400- 1499, 4600- 4799, and 4900- 4999.    C. Billing Requirements    The CMHCs bill for partial hospitalization services under bill type 76X.  CMHCs are required to report condition code 41 in FLs 18- 28 to indicate the claim is for partial hospitalization program services. The A/B MACs (A) follow bill review instructions in chapter 25 of this manual, except for those listed below.    The acceptable revenue codes are as follows:    Revenue  Code  Descripon  0250  Drugs and Biologicals  043X  Occupaonal Therapy  0900  Behavioral Health Treatments/Services  0904  Acvity Therapy  0910  Psychiatric/Psychological Services (Dates of Service prior to  October 16, 2003)  0914  Individual Therapy  0915  Group Therapy  0916  Family Therapy  0918  Behavioral Health/Tesng  0942  Educaon/Training    The CMHCs are also required to report appropriate HCPCS codes as follows:    Revenue Codes  Descripon  HCPCS Code  043X  Occupaonal Therapy   *G0129 ( PHP/IOP )  0900  Behavioral Health  Treatments/Services  ****90791 or *****90792 , 97153, 97154, 97155, 97156, 97157, 97158      0904  Acvity Therapy   **G0176 ( PHP/IOP )        0914  Individual Psychotherapy  90785, 90832, 90833, 90834, 90836,  90837, 90838, 90839, 90840,  90845, 90865, 90880 , 90899     0915  Group Psychotherapy  G0410 , G0411 , 90853      0916  Family Psychotherapy  90846 , or 90847 , 90849   0918  Behavioral Health/Tesng  96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138 , 96139, 96146 96156, 96158, 96161, 96164, 96167, 97151, 97152   0942  Educaon/Training  G0023, G0024, G0140, G0146, ***G0177 , G0451, 96202, 96203, 97550, 97551, 97552     The A/B MAC(s) (A) edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  They do not edit for the matching of revenue codes to HCPCS.    Definitions of each of the asterisked HCPCS codes follow :