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Hospital-based PHP Billing Guide - JF Part A

Hospital-based PHP Billing Guide

Requirement	Description
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 CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, 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 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 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 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 CMS Medicare Learning 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 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) Independtly Practicing Psychologists (IPP)
PHP Services	A PHP is furnished by a hospital to outpatients that provides parital 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 paritial 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 CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 260.1	APC payment rate for PHP 5853 - Partial Hospitalization (3 or more services per day) for hospital-based PHPs
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

Last Updated Fri, 12 Aug 2022 20:08:09 +0000