(Medicare Benefit Policy Manual)

A program comprised primarily of diversionary activity, social, or recreational therapy does not constitute a PHP.  Psychosocial programs which provide only a structured environment, socialization, and/or vocational rehabilitation are not covered by Medicare.  A program that only monitors the management of medication for patients whose psychiatric condition is otherwise stable, is not the combination, structure, and intensity of services which make up active treatment in a PHP.    B. Patient Eligibility Criteria    1. Benefit Category    Patients must meet benefit requirements for receiving the partial hospitalization services as defined in 1861(ff) and 1835(a)(2)(F) of the Act.  Patients admitted to a PHP must be under the care of a physician who certifies the need for partial hospitalization , including the need for  a minimum of 20 hours per week of therapeutic services, as evidenced by their plan of care.  The patients also require a comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder (including SUD)  which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning.  Such dysfunction generally is of an acute nature.  In addition, PHP patients must be able to cognitively and emotionally participate in the active treatment process, and be capable of tolerating the intensity of a PHP program.    Patients meeting benefit category requirements for Medicare coverage of a PHP comprise two groups: those patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment; or those patients wh o, in the absence of partial hospitalization, would be at reasonable risk of requiring inpatient hospitalization.  Where partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP.  Recertification must address the continuing serious nature of the patients psychiatric condition requiring active treatment in a PHP.    Discharge planning from a PHP may reflect the types of best practices recognized by professional and advocacy organizations that ensure coordination of needed services and follow -up care.  These activities include linkages with community resources, support s, and providers in order to promote a patients return to a higher level of functioning in the least restrictive environment.    2. Covered Services     Items and services that can be included as part of the structured, multimodal active treatment program, identified in 1861(ff)(2) include:     Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, mental health counselors, marriage and family therapists, clinical nurse specialists, certified alcohol and drug counselors);     Occupational therapy requiring the skills of a qualified occupational therapist.  Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;     Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients (including patients with SUD) .  These include principal illness navigation services provided by auxiliary staff, including peer support specialists ;     Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);     Individualized activity therapies that are not primarily recreational or diversionary.  These activities must be individualized and essential for the treatment of the patients diagnosed condition and for progress toward treatment goals;     Family counseling services for which the primary purpose is the treatment of the patients condition .  These include counseling services for caregivers ;     Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition.  These services include caregiver training services furnished for the benefit of the patient ; and     Medically necessary diagnostic services related to mental health treatment (including SUD) .   Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial.  It is not enough that a patient qualify under the benefit category requirements in or of 1835(a)(2)(F) unless the patient  also has the need for the active treatment provided by the program of services defined in 1861(ff).  It is the need for at least 20 hours per week of  intensive, active treatmen t of the patient's  condition to maintain a functional level and  to prevent relapse or hospitalization that  qualifies the patient to receive the services identified in 1861(ff).    3. Reasonable and Necessary Services    This program of services provides for the diagnosis and active, intensive treatment of the individuals serious psychiatric condition (including SUD)  and, in combination, are reasonably expected to improve or maintain the individuals condition and functional level and prevent relapse or hospitalization.  A particular individual covered service (described above) as intervention, expected to maintain or improve the individuals condition and prevent relapse, may also be included within the plan of care, but the overall intent of the partial program admission is to treat the serious presenting psychiatric symptoms (including SUD) .  Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent hospitalization.    Patients admitted to a PHP do not require 24 hour per day supervision as provided in an inpatient setting, must have an adequate support system to sustain/maintain themselves outside the PHP and must not be an imminent danger to themselves or others.  Pati ents admitted to a PHP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5, of the version of the International Classification of Diseases (ICD) applicable to the service date, which severely interferes with multiple areas of daily life.  Examples include eating disorders, mood disorders, psychotic disorders, and substance use disorders.  The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from participating in an active treatment program.  It is the need, as certified by the treating physician, for the intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patients presenting psychiatric condition (including SUD) .    For patients who do not meet this degree of severity of illness, and for whom partial hospitalization services are not necessary for the treatment of a psychiatric condition (including SUD) , professional services billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even though partial hospitalization services are not.    Patients in PHP may be discharged by either stepping up to an inpatient level of care which would be required for patients needing 24 -hour supervision, or stepping down to a less intensive level of outpatient care when the patients clinical condition impr oves or stabilizes and the patient  no longer requires structured, intensive, multimodal treatment.    4. Reasons for Denial    a. Benefit category denials made under 1861(ff) or 1835(a)(2)(F) are not  appealable by the provider and the limitation on liability provision does not apply (HCFA Ruling 97- 1).  Examples of benefit category based in 1861(ff) or 1835(a)(2)(F) of the Act, for partial hospitalization services generally include the following:     Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;     Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or     Patients who are otherwise psychiatrically stable or require medication management only.    b. Coverage denials made under 1861(ff) of the Act are not appealable by the  provider and the Limitation on Liability provision does not apply (HCFA Ruling 97-1).  The following services are excluded from the scope of partial hospitalization services defined in 1861(ff) of the Social Security Act:     Services to hospital inpatients;   Meals, self -administered medications, transportation; and   Vocational training.    c. Reasonable and necessary denials based on 1862(a)(1)(A) are appealable and the Limitation on Liability provision does apply.  The following examples represent reasonable and necessary denials for partial hospitalization services and coverage is excluded u nder 1862(a)(1)(A) of the Social Security Act:     Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or     Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.    5. Documentation Requirements and Physician Supervision    The following components will be used to help determine whether the services provided were accurate and appropriate.    a. Initial Psychiatric Evaluation/Certification .--Upon admission, a certification by  the physician must be made that the patient admitted to the PHP would require inpatient psychiatric hospitalization if the partial hospitalization services were not provided and that the patient requires at least 20 hours of services per week .  The certification should identify the diagnosis and clinical need for the partial hospitalization.  Partial hospitalization services must be furnished under an individualized written plan of care, established by the physician, which includes the active treatment prov ided through the combination of structured, intensive services identified in 1861 that are reasonable and necessary to treat the presentation of serious psychiatric symptoms (including SUD)  and to prevent relapse or hospitalization.    b. Physician Recertification Requirements .--     Signature  The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patients response to treatment.     Timing  The first recertification is required as of the 18th calendar day following admission to the PHP.  Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days.     Content  The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the PHP and describe the following:     The patients response to the therapeutic interventions provided by the PHP;     The patients psychiatric symptoms (including SUD)  that continue to place the patient at risk of hospitalization; and     Treatment goals for coordination of services to facilitate discharge from the PHP.    c. Treatment Plan .--Partial hospitalization is active treatment pursuant to an  individualized treatment plan, prescribed and signed by a physician, which identifies treatment goals, describes a coordination of services, is structured to meet the particular needs of the patient, and includes a multidisciplinary team approach to patien t care.  The treatment goals described in the treatment plan should directly address the presenting symptoms and are the basis for evaluating the patients response to treatment.  Treatment goals should be designed to measure the patients response to acti ve treatment.  The plan should document ongoing efforts to restore the individual patient to a higher level of functioning that would permit discharge from the program, or reflect the continued need for the intensity of the active therapy to maintain the individuals condition and functional level and to prevent relapse or hospitalization.  Activities that are primarily recreational and diversionary, or provide only a level of functional support that does not treat the serious presenting psychiatric symptom s (including SUD)  placing the patient at risk, do not qualify as partial hospitalization services.    d. Progress Notes.--Section 1833(e) of the Social Security Act prevents Medicare  from paying for services unless necessary and sufficient information is submitted that shows that services were provided and to determine the amounts due.  A provider may submit progress notes to document the services that have been provided.  The progress note should include a description of the nature of the treatment service, the patients response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.    See the Medicare Claims Processing Manual, Chapter 4, Hospital Outpatient Services, 260 for billing instructions for partial hospitalization services.   70.4 - Intensive Outpatient Services  (Rev.  12425; Issued: 12-21- 23: Effective: 01 -01-24; Implementation: 01-02-24)     Intensive outpatient programs (IOPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in  1861(ff)  of the Social Security Act (the Act).  An IOP furnishes treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation, but less intense than a PHP.  Programs providing primarily social, recreational, or diversionary activities are not considered intensive outpatient programs.    A. Program Criteria