(Medicare Claims Processing Manual)

 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 and occupational therapists), are bundled when furnished to hospital patients, including partial hospitalization patients.  The hospital mu st 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 250).  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 servic e 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  2017 and subsequent years, the payment structure for partial hospitalization  services provided in hospital outpatient departments and CMHCs has been reduced from four APCs (two for CMHCs and two for hospital- based PHPs) to a single APC by provider type.  Effective January 2, 2017, we are replacing existing CMHC APCs 5851 (Level 1 Partial Hospitalization (3 services)) and 5852 (Level 2 Partial Hospitalization (4 or more services)) with a new CMHC APC 5853 (Partial Hospitalization (3 or More Services Per Day)), and replacing existing hospital- based PHP APCs 5861 (Level 1 Partial Hospitalization (3 services)) and 5862 (Level 2 Partial Hospitalization (4 or more services)) with a new hospital-based PHP APC 5863 (Partial Hospitalization (3 or More Services Per Day)).  The following chart displays the CMHC and hospital- based PHP  APCs:   Hospital- Based and Community Mental Health Center PHP APCs   CY 2017 APC  Group Title  5853 Partial Hospitalization (3 or more services per day) for CMHCs  5863 Partial Hospitalization (3 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 Hospitalizatio n Services Provided in Community Mental Health Centers (CMHC)  (Rev. 4204, Issued: 01- 17-19, Effective: 01-01-19, Implementation: 01-07-19)   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 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.  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  Description  0250  Drugs and Biologicals  043X  Occupational Therapy  0900  Behavioral Health Treatments/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   The CMHCs are also required to report appropriate HCPCS codes as follows:   Revenue Codes  Description  HCPCS Code  043X  Occupational Therapy  *G0129 (Partial Hospitalization)  0900  Behavioral Health Treatments/Services  ****90791 or *****90792   0904  Activity Therapy  **G0176 (Partial Hospitalization)     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  Behavioral Health/Testing  96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138. 96139, 96146  0942  Education/Training  ***G0177   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 each of the asterisked HCPCS codes follows:    *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 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 partial hospitalization programs.   Code G0177 may be used in both partial hospitalization program 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 manual.  The professional services lis ted 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 t he 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 bu ndled 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 revenue code in subsection C.   EXAMPLE:  A benefic iary 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 second 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 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