(Medicare Claims Processing Manual)

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 :   *The definition of code G0129 is as follows:  Occupational therapy services requiring the 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 health 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 or  partial hospitalization programs.    Code G0177 may be used in partial hospitalization programs , intensive outpatient programs, and outpatient mental health settings.    Revenue code 0250 does not require HCPCS coding.  However, drugs that can be self -administered are not covered by Medicare.    HCPCS includes CPT -4 codes.  See the ASC X12 837 institutional claim guide for how to report HCPCS electronically.  CMHCs report HCPCS codes on Form CMS -1450 in FL44, HCPCS/Rates.  HCPCS code reporting is effective for claims with dates of service on or after April 1, 2000.    The A/B MACs (A) are to advise their CMHCs of these requirements.  CMHCs should complete the remaining items on the claim in accordance with the ASC X12 837 Institutional Claim implementation guide and the Form CMS -1450 instructions in Chapter 25 of this m anual.    The professional services listed below are separately covered and are paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practitioners (other than physician assistants (PAs)) bill the A/B MAC (B) directly for the professional services furnished to CMHC partial hospitalization patients.  The ASC X12 837 professional claim format or the paper form 1500 is used.    The CMHC can also serve as a billing agent for these professionals by billing the A/B  MAC (B) on their behalf for their professional services.  The professional services of a PA can be billed to the A/B MAC (B) only by the PAs 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 CMHC, the physician and not the CMHC would be responsible for billing the A/B MAC (B) for the services of the PA.    The following 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;     PA services, as defined in 1861(s)(2)(K)(i)  (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act;     Nurse practitioner and clinical nurse specialist services, as defined in  1861(s)(2)(K)(ii)  (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act; and,     Clinical psychologist services, as defined in 1861(ii)  (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act.    The services of other practitioners (including clinical social workers and occupational therapists) are bundled when furnished to CMHC patients.  The CMHC must bill the A/B MAC (A) for such nonphysician practitioner services as partial hospitalization services.  The A/B MAC (A) makes payment for the services to the CMHC.    D. 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) as partial hospitalization services.   E. Reporting of Service Units    Visits should no longer be reported as units.  Instead, CMHCs report in the field, Service Units, the number of times the service or procedure, as defined by the HCPCS code, was performed when billing for partial hospitalization services identified by re venue code in subsection C.    EXAMPLE:  A beneficiary received psychological testing performed by a physician for a total of 3 hours during one day (HCPCS code 96130, first hour; HCPCS code 96131 for 2 additional hours).  The CMHC reports revenue code 0918, HCPCS code 96130, and 1 unit; and a se cond line on the claim showing revenue code 918, HCPCS code 96131, and 2 units.    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.    The CMHC need not report service units for drugs and biologicals (Revenue Code 0250) .    NOTE : Information regarding the Form CMS -1450 form locators that correspond with these fields is found in Chapter 25 of this manual.  See the ASC X12 837 Institutional Claim implementation guide for related guidelines for the electronic claim.    F. Line Item Date of Service Reporting    Dates of service per revenue code line for partial hospitalization claims that span two or more dates.  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 Service Date.  See examples below of reporting line item dates of service.  These examples are for group therapy services provided twice during a billing period.    For claims, report as follows:    Revenue  Code  HCPCS  Dates of  Service  Units  Total  Charges  0915  G0410  20240505  1  $80  0915  G0410  20240529  2  $160    NOTE : Information regarding the Form CMS -1450 form locators that correspond with these fields is found in Chapter 25 of this manual.  See the ASC X12 837 Institutional Claim Implementation Guide for related guidelines for the electronic claim.    The A/B MACs (A) return to provider claims that span two or more dates if a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement covers period.  Line item date of service reporting is effective for claims with dates of service on or after June 5, 2000.    G. Payment    Section 1833(a)(2)(B) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm )  of the Act provides the statutory authority governing payment for partial hospitalization services provided by a CMHC.  A/B MAC(s) (A) made payment on a reasonable cost basis until OPPS was implemented.  The Part B deductible and coinsurance applied.    Payment principles applicable to partial hospitalization services furnished in CMHCs are contained in 2400 of the Medicare Provider Reimbursement Manual.    The A/B MACs (A) make payment on a per diem basis under the hospital outpatient prospective payment system for partial hospitalization services.  CMHCs must continue to maintain documentation to support medical necessity of each service provided, including the beginning and ending time.    Effective January 1, 2011, there were four separate APC payment rates for PHP:  two for CMHCs (for Level I and Level II services based on only CMHC data) and two for hospital -based PHPs (for Level I and Level II services based on only hospital -based PHP da ta).      The two CMHC APCS for providing partial hospitalization services were:  APC 5851  (Level 1 Partial Hospitalization (3 services)) and APC 5852 (Level 2 Partial  Hospitalization (4 or more services)).  Effective January 1, 2017, APCs 5851 and 5852 were combined  into one new APC 5853 (Partial Hospitalization (3 or more services) for CMHCs).   Effective January 1, 2024, there are two APC payment rates for CMHC PHPs: APC 5853 (Level 1 Partial Hospitalization (3 or fewer services per day)) and APC 5854 (Level 2 Partial Hospitalization (4 or more services per day)).    Community Mental Health Center PHP APC   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    NOTE: Occupational therapy services provided to partial hospitalization patients are not subject to the prospective payment system for outpatient rehabilitation services, and therefore the financial limitation required under 4541 of the Balanced Budget Act (BBA ) does not apply.    H. Medical Review    The A/B MACs (A) follow medical review guidelines in Pub. 100- 08, Medicare Program Integrity Manual.    I. Coordination with CWF    See chapter 27 of this manual.  All edits for bill type 74X apply, except provider number ranges 4600- 4799 are acceptable only for services provided on or after October 1, 1991.   260.2 - Professional Services Related to Partial Hospitalization  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   A3-3661    The professional services listed below when provided in a hospital or CAH outpatient department are separately covered and paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practit ioners (other than physician assistants (PA)) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient partial hospitalization patients.  The hospitals or CAHs can also serve as a billing agent for these profess ionals by billing the A/B MAC (B) on their behalf under their billing number for their professional services.  Only a PAs employer can bill the A/B MAC (B) for professional services of a 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 or CAH patients, including partial hospitalization patients.  The hospital or CAH must bill their A/B MAC (A) for such nonphysician practitioner services as partial hospitalization servi ces.  Payment is made to the provider for these services.    Only the actual employer of the PA can bill for these services.  The employer of a PA may be such entities or individuals such 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 hospital or CAH, the physician and not the hospital or CAH is responsible for billing the A/B MAC (B) on the Form CMS -1500 for the services of the PA.   260.3 - Outpatient Mental Health Treatment Limitation for Partial Hospitalization Services  (Rev. 1, 10- 03-03) A-01-93  The outpatient mental health treatment limitation applies to services to partial hospitalization patients to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CAHs, and PAs.  It does not appl y to such mental health treatment services billed to the A/B MAC (A) by a CMHC, hospital or CAH as partial hospitalization services.