Hospital-based PHP Billing Guide - JE Part A
Hospital-based PHP Billing Guide
Bill Types
Hospitals
- 131 - Admit through discharge
- 132 - Interim - First
- 133 - Interim - Continuing
- 134 - Interim - Last
Critical Access Hospital (CAHs)
- 851 - Admit through discharge
- 852 - Interim - First
- 853 - Interim - Continuing
- 854 - Interim - Last
Condition Code
Hospitals and CAHs report condition code 41 to indicate claim is for partial hospitalization services
Community Mental Health Center (CMHC) Revenue Codes
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 3, Section 260.1.1C
Hospitals other than CAHs are also required to report these CPT/HCPCS
- G0129 - Occupational Therapy (Partial Hospitalization)
- 90791 or 90792 - Behavioral Health 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
- 96116 - 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
Effective January 1, 2013
- Submit claim in service date sequence as services are furnished
- Prior claim must be finalized or incoming claim with 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)
- Independently Practicing Psychologists (IPP)
PHP Services
A PHP is furnished by a hospital to outpatients that provides partial hospitalization services. Partial hospitalization services are a distinct and organized intensive ambulatory psychiatric treatment program that offers less than twenty-four hour daily care to patients who either:
- Have been discharged from inpatient hospital treatment
- Would be at reasonable risk of requiring inpatient hospitalization in absence of partial hospitalization
- Active treatment is furnished that incorporates an individual plan of care with a coordination of services designed to needs of patient
- Treatment includes a multidisciplinary team approach to care under direction of a physician and for a minimum of 20 hours per week
- Treatment goals
- Patient requires comprehensive, highly structured and scheduled multimodal treatment that requires medical supervision and coordination under plan of care
- Patient is able to cognitively and emotionally participate in active treatment
Non-PHP Services
Below items 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
- 5863 - Partial Hospitalization (3 or more services per day) for hospital-based PHPs
- 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 hospital outpatient department as partial hospitalization services.
PHP Deductible/Coinsurance
Part B deductible and coinsurance does apply
