(Medicare Claims Processing Manual)

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 ses sions 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  G0176  20090505  1 $80 0915  G0176  20090529  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 M ACs (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.  Paym ent 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 rat es 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 data).    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, we are combining APCs 5851 and 5852 into one new APC 5853 (Partial Hospitalization (3 or m ore services) for CMHCs).   Community Mental Health Center PHP APC  APC  Group Title  5853  Partial Hospitalization (3 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. 1, 10- 03-03) 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 phy sicians and other practitioners.  These professional services are unbundled and these practitioners (other than physician assistants (PA)) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient partial hospita lization patients.  The hospitals or CAHs 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.  Only a PAs employer can bill the A/B MAC (B) for pr ofessional 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 p ayment 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 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 services.  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 physic ian 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 Treatm ent 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 apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC, hospital or CAH as partial hospitalization services.   260.4 - Reporting Service Units for Partial Hospitalization  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Hospitals report 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 .  EXAMPLE:  A beneficiary received psychological testing (HCPCS code 96100 which is defined in one -hour intervals) for a total of three hours during one day.  The hospital reports revenue code 0918 in FL 42, HCPCS code 96100 in FL 44, and three units in FL 46.  The CAH would report revenue code 0918, leave HCPCS blanks, and report 1 unit in FL 46.   When reporting service units for HCPCS codes where the definition of the procedure does not include any reference to time (either in minutes , hours, or days), hospital outpatient departments do not bill for sessions of less than 45 minutes.  The A/B MAC (A) must return to the provider claims other than CAH claims that do not contain service units for each HCPCS code.   NOTE:  Service units do not need to be reported for drugs and biologicals (Revenue Code 0250).  Hospitals must retain documentation to support the medical necessity of each service provided, including beginning and ending time.   260.5 - Line Item Date of Service Reporting for Parti al Hospitalization  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)  Hospitals other than CAHs are required to report line item dates of service per  revenue code line for partial hospitalization claims.  Where services are provided on more than one day included in the billing period, the date of service must be identified.  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.  See examples below of reporting line item dates of service.  These examples are for group therapy services provided twice during a billing period.   For the claims, report as follows:    Revenue Code  HCPCS  Dates of Service  Units  Total Charges  0915  G0176  20090505  1 $80.00  0915  G0176  20090529  2 $160.00   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 MAC (A) must return to the hospital (RTP) claims where 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.   260.6 - Payment for Partial Hospitalization Services  (Rev. 3685, Issued: 12- 22-16, Effective: 01- 01-17, Implementation: 01- 03-17)  For hospital outpatient departments, the A/B MAC (A) makes payments on a reasonable cost basis until August 1, 2000 for partial hospitalization services.  The Part B deductible and coinsurance apply.  During the year, the A/B MAC (A) will make payment at an interim rate based on a percentage of the billed charges.  At the end of the year, the hospital will be paid at the reasonable cost incurred in furnishing partial hospitalization  services, based upon the Medicare cost report filed with the A/B MAC (A).  Beginning with services provided on or after August 1, 2000, payment is made under the hospital outpatient prospective payment system for partial hospitalization services.   For CAH s, payment is made on a reasonable cost basis regardless of the date of service.   In CY 2017, payment for non- excepted off -campus hospital -based PHPs will be made under the MPFS, paying the CMHC per diem rate for APC 5853, for providing 3 or more PHP servi ces per day.   The Part B deductible, if any, and coinsurance apply.   270 - Billing for Hospital Outpatient Services Furnished by Clinical Social Workers (CSW)  (Rev. 1, 10- 03-03) A3-3662   Payment may be made for covered diagnostic and therapeutic services f urnished by CSWs in a hospital outpatient setting.  CSW services furnished under a partial hospitalization program are included in the partial hospitalization rate.  Other CSW services must be billed to the A/B MAC (B) on Form CMS -1500 or the electronic equivalent.    See chapters 13 and 15, of the Medicare Benefit Policy Manual, for a discussion of the coverage requirements for CSW.   270.1 - Fee Schedule to be Used for Payment for CSW Services  (Rev. 1, 10- 03-03)  The fee schedule for CSW services is set at 75 percent of the fee schedule for comparable services furnished by clinical psychologists, except for services under a CAH partial hospitalization program.  These are paid on a reasonable cost basis.   270.2 - Outpatient Mental Health Payment Limitation fo r CSW Services  (Rev. 1, 10- 03-03)  The CSW services are subject to the outpatient mental health services limitation in 1833 of the Act.  The imitation of 62.5 percent is applied to the lesser of the actual charge or fee schedule amount.  Diagnostic services are not subject to the limitation.   270.3 - Coinsurance and Deductible for CSW Services  (Rev. 1, 10- 03-03)  The annual Pa rt B deductible and the 20 percent coinsurance apply to CSW services.