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
  • G0716 - 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 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 Tue, 03 Mar 2020 11:48:47 +0000