CMHC PHP Billing Guide

Requirement Description
Unique Identifying Provider Number Ranges 3rd - 6th digits
  • 1400 - 1499
  • 4600 - 4799
  • 4900 - 4999
Bill Type
  • 761 - Admit through discharge
  • 762 - Interim - First
  • 763 - Interim - Continuing
  • 764 - Interim - Last

Community Mental Health Center (CMHC) Revenue Codes

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 260.1.1C

Partial Hospitalization Program (PHP) services must be billed with below revenue codes and a CPT or HCPCS code descripting encounter

  • 0250 - Drugs and Biologicals
  • 043x - Occupational Therapy
  • 0900 - Behavioral Health Treatment/Services
  • 0904 - Activity Therapy  
  • 0914 - Individual Therapy
  • 0915 - Group Therapy
  • 0916 - Family Therapy
  • 0918 - Testing
  • 0942 - Education Training

CPT/HCPCS for PHP Reimbursement

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 260.1.1C

CMHCs are also required to report these CPT/HCPCS
  • G0129 - Occupational Therapy (Partial Hospitalization)
  • 90791 or 90792 - Behavioral Helath Treatment/Services
  • G0176 - Activity Therapy (Partial Hospitalization)
  • 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, or 90880 - Individual Psychotherapy
  • G0410 or G0411 - Group Pyshcotherapy
  • 90846 or 90847 - Family Psychotherapy
  • 96101, 96102, 96103, 96116, 96118, 96119, or 96120 - Psychiatric Testing
  • G0177 - Education Training
Service Units Report number of times a service or procedure was performed as described by code descriptor
Line Item Date of Service (LIDOS) Report LIDOS per revenue code

Interim Billing on PHP Claims

CMS Medicare Learing Network (MLN) Matters (MM)8048

Effective January 1, 2013
  • Submit claim in service date sequence as services are furnished
  • Prior claim must be finalized or incoming claim will return to provider (RTP)
Eligible Professionals
  • Physicians
  • Nurse practitioners (NP)
  • Physician assistants (PA)
  • Clinical nurse specialists (CNS)
  • Certified nurse midwives (CNM)
  • Clinical psychologist (CP)
  • Clinical Social Worker (CSW)
  • Independtly Practicing Psychologists (IPP)
CMHC Services A CMHC is an entity that provides partial hospitalization services under Part B. To be authorized to provide these services, a CMHC must provide:
  • Outpatient services including specialized outpatient services for children, older adults, individuals who are chronically mentally ill, and residents of its mental health service area
  • 24-hour emergency care services that provide access to a clinician and appropriate disposition with follow-up documentation of the emergency in the patient's medical record
  • Day treatment or other partial hospitalization services, or psychosocial rehabilitation services that provide structured day programs with treatment plans that vary in intensity
  • At least 40 percent of its services to individuals who are not eligible for benefits under Title XVIII of the Social Security Act
  • Screening for patients who are being considered for admission to a State mental health facility to determine the appropriateness of such admission by an entity that has the appropriate clinical personnel and authorization under State law to perform all steps in the clinical evaluation process
Non-PHP Services

The below are not PHP services and are paid according to Medicare provisions for each type of service.

  • Services to hospital inpatients
  • Meals
  • Self-administered medications
  • Transportation
  • Vocational Training (Career)

Payment for PHP

APC payment rate for PHP

  • 5853 - Partial hospitalization (3 or more services per day) for CMHCs
Frequency of Billing Monthly claims in sequence date order
Treatment Limitation Outpatient mental health treatment limitation does not apply to such mental health services billed by a CMHC as partial hospitalization services
PHP Deductible/Coinsurance Part B deductible and coinsurance does apply

 

Last Updated Fri, 28 Feb 2020 13:30:44 +0000