(Medicare Claims Processing Manual)

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.   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 CA H 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 Partial Hospitalization  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    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 se rvices provided twice during a billing period.    For the claims, report as follows:    Revenue Code  HCPCS  Dates of Service  Units  Total  Charges  0915  G0410  20240505  1  $80.00  0915  G0410  20240529  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. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   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 CAHs, payment is made on a 101%  reasonable cost basis regardless of the date of service.    In CY 2024, 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 up to 3 PHP services per day and APC 5854, for providing 4 or more PHP services per day .    The Part B deductible, if any, and coinsurance apply.   261 - Intensive Outpatient Program Services (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)  Medicare Part B coverage is available for Intensive Outpatient Program (IOP) services on or after January 1, 2024 provided by hospitals, CAHs, CMHCs, RHCs, FQHCs, and Opioid Treatment Programs (OTPs). See chapter 9 in this manual for billing instructions for provider -based and independent RHC/FQHC services. See chapter 39 in this manual for billing instructions for OTPs.   261.1 - Special Intensive Outpatient Program Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Medicare Part B coverage is available for hospital outpatient intensive outpatient program services.   A. Billing Requirement   Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act defines the services under the intensive outpatient program benefit in a hospital.   Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) recognizes CMHCs as providers of services but only for furnishing intensive outpatient program and partial hospitalization services.  See 261.1.1 of this chapter for CMHC intensive outpatient program bill review directions.   Hospitals and CAHs report condition code 92 in FLs 18- 28 (or electronic equivalent) to indicate the claim is for intensive outpatient program services.  They must also report a revenue code and the charge for each individual covered service furnished.  I n addition, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.  Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under an intensive outpatient program .  In addition, hospital outpatient departments are required to report HCPCS codes.  Component billing assures that only those intensive outpatient program  services covered under 1861(ff) of the Act are paid by the Medicare program.   Effective January 1, 2024, for intensive outpatient program services, non -excepted off -campus provider -based departments of a hospital are required to report a PN modifier on each claim line for non- excepted items and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modif ier to be reported with each non- excepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.  Effective January 1, 2024, for intensive outpatient program services, 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.   All hospitals are required to report condition code 92 in FLs 18- 28 to indicate the claim is for intensive outpatient program services.  Hospitals use bill type 013X and CAHs use bill type 085X.  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  Description  HCPCS Code  043X  Occupational Therapy  *G0129 ( PHP/IOP ) 0900  Behavioral Health Treatment/Services  ****90791 or ***** 90792, 97153, 97154, 97155, 97156, 97157, 97158   0904  Activity Therapy  **G0176 ( PHP/IOP ) 0914  Individual Psychotherapy  90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90865, 90880, 90899     0915  Group Therapy  G0410 , G0411 , 90853     0916  Family Psychotherapy  90846 , 90847 , 90849  0918  Behavioral Health/Testing  96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96161, 96164, 96167, 97151, 97152  0942  Education/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 patient s 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 patient s 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 nonphysician.  *****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