Partial Hospitalization Program Interim Billing Guidelines

(1)

Partial Hospitalization Program

Interim Billing Guidelines

March 2013

(2)

Today’s Presenters

• Christine Janiszcak, Provider Outreach &

Education Consultant

• Pat Zachmann, Provider Outreach &

Education Consultant

(3)

3 National Government Services, Inc.

Today's PowerPoint Presentation

• PowerPoint available on events calendar

– Go to the http://www.NGSMedicare.com Web site

– Select Medicare Part A Home Page

– Click on the Training Events Calendar

underneath Education and Training section – Select the J13: Partial Hospitalization

Program Interim Billing Guidelines

– Under attachments you will see the PowerPoint presentation link

(4)

Disclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or

liability for the results or consequences of the use of this material.

Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the

Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov.

(5)

No Recording

• Attendees/providers are

never

permitted

to record (tape record or

any

other

method) our educational events

– This applies to our Webinars,

teleconferences, live events, and any other type of National Government Services

(6)

Acronyms

• APC – Ambulatory Payment Classification

• CAH – Critical Access Hospital

• CC – Condition code

• CMHC – Community Mental Health Center

• CMS – Centers for Medicare & Medicaid Services

• CNS – Clinical Nurse Specialist

• CPT – Current Procedural Terminology

• CR – Change request

• CSW – Clinical Social Worker

• CY – Cost year

• DOS – Date of service

(7)

Acronyms

• FL – Form locator

• HCPCS – Healthcare Procedure Coding System

• HIPPS – Health Insurance Prospective Payment System

• HOPD – Hospital Outpatient Department

• IOM – Internet-only manual

• LCD – Local coverage determination

• LIDOS – Line item date of service

• LOA – Leave of absence

• LOC – Level of care

• MAC – Medicare Administrative Contractor

• MUC – Medicare University Credit

(8)

Acronyms

• NUBC – National Uniform Billing Committee

• OSC – Occurrence Span Code

• PA – Physician Assistant

• PHP – Partial Hospitalization Program

• PSC – Patient status code

• RTP – Return to provider

• SAD – Self-administered drugs

• SIA – Supplemental Instructions article

(9)

Objectives

• Provide high-level overview of PHP

coverage guidelines

• Provide instructions for submitting PHP

claims

• Provide instructions for submitting interim

PHP claims effective 04/01/13 per CR 8048

(10)

Agenda

• Partial hospitalization program

• Coverage guidelines

• Billing requirements

• Payment

• Interim billing

• Consistency editing

• Resources

• What you should do now

• Wrap up

(11)

Partial Hospitalization

Program (PHP) and PHP

(12)

Partial Hospitalization Program

• Distinct and organized intensive treatment

program for patients who would otherwise

require inpatient psychiatric care

• May be covered under Medicare Part B

when provided by a HOPD (including a

CAH) or a Medicare-certified CMHC

• Closely resembles highly structured

short-term hospital inpatient program

(13)

Polling Question #1

• Please indicate the facility type for which

you submit PHP claims to Medicare

1. Community mental health center 2. Critical access hospital

(14)

PHP Services

• Partial hospitalization services

– Active treatment

– Incorporate individualized treatment plan

• Describes coordination of services around patient’s needs

• Includes a multidisciplinary team approach under direction of a physician

– Reflect high degree of structure and scheduling

• Treatment goals should be

– Measurable, functional, time-framed, medically necessary, and directly related to reason for admission

(15)

Patient PHP Eligibility Criteria

• Patients admitted to a PHP

– Must be under care of a physician who certifies need

– Require minimum 20 hours/week therapeutic services

– Require comprehensive, structured, multimodal treatment

• Requiring medical supervision and coordination

• Provided under an individualized plan of care

• Because of a mental disorder (mental health diagnosis) which severely interferes with multiple areas of daily life

– Must be able to participate in treatment and tolerate intensity of PHP

(16)

PHP Covered Services

• Individual or group psychotherapy • Occupational therapy

• Services of staff

• Drugs and biologicals; not self-administered

• Individualized activity therapies; not recreational • Family counseling services

• Patient training and education

• Medically necessary diagnostic services related to mental health treatment

(17)

Did You Know…

• PHP services must be vigorous and

proactive as opposed to passive and

custodial. It is the need for intensive,

active treatment to maintain a functional

level and to prevent relapse or

hospitalization that qualifies the patient to

receive PHP services.

(18)

PHP - Reasonable and Necessary

• Provides for diagnosis and active, intensive treatment of patient’s serious psychiatric condition

• Reasonably expected to improve or maintain condition and functional level and prevent relapse or hospitalization

• Overall intent to treat serious psychiatric symptoms

• Continued treatment to maintain stable psychiatric

condition/functional level – requires evidence that less intensive options cannot provide necessary support

(19)

Did You Know…

• Patients who do not meet the degree of severity of illness for the PHP may still require the

professional services of psychiatrists and psychologists.

• Patients in a PHP may be discharged by

stepping up to an inpatient LOC (required for patients needing 24-hour supervision) or

stepping down to a less intensive treatment (patient’s condition improves).

(20)

Noncovered Services

• Benefit category denials (not appealable)

– Day care programs

– Programs attempting to maintain psychiatric wellness

– Patient psychiatrically stable; requires medication only

• Coverage denials (not appealable)

– Services to hospital inpatients

– Meals, SADs, transportation

(21)

Noncovered Services

• Reasonable and necessary denials

(appealable)

– Patients who cannot, or refuse to participate with active treatment

– Treatment of chronic conditions without acute exacerbation of symptoms

(22)

Documentation and Physician

Supervision

• Initial psychiatric evaluation/certification

– Upon admission, a certification by physician must be made that patient would require

inpatient psychiatric hospitalization if PHP were not provided

– Should identify diagnosis and psychiatric need for PHP

(23)

Documentation and Physician

Supervision

• Physician recertification including:

– Physician signature – Timing

– Content

– Patient’s psychiatric symptoms

(24)

Documentation and Physician

Supervision

• Treatment plan

– Prescribed and signed by a physician – Identifies treatment goals

– Describes a coordination of services – Structured to meet needs of patient

– Includes a multidisciplinary team approach to patient care – Documents ongoing efforts to restore patient to a higher

level of functioning that would permit discharge or

– Reflects continued need for intensity of active therapy to maintain individual’s condition and functional level and to prevent relapse or hospitalization

(25)

Documentation and Physician

Supervision

• Goals of treatment plan

– Directly address presenting symptoms – Basis for evaluating patient’s response to

treatment

– Designed to measure patient’s response to active treatment

(26)

Documentation and Physician

Supervision

• Progress notes; should include:

– Description of nature of treatment service

– Patient’s response to therapeutic intervention and its relation to goals indicated in treatment plan

(27)

Did You Know…

• If all PHP program and patient eligibility

requirements are met, including reasonable

and necessary requirements, PHP services

are an unlimited benefit for a Medicare

(28)

PHP Coverage References

• CMS

– CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.3

• National Government Services

– LCD 26398 & SIA A45932 – LCD & Article for PHPs

• http://NGSMedicare.com > Coverage Determinations > Medical Policy Center

(29)

(30)

Polling Question #2

• Please indicate how long you have been

submitting PHP claims to Medicare

1. Less than one year

2. Between one year and four years 3. Five years or more

(31)

PHP Billing Requirements –

Claim Forms and Fields

• PHP facility services

– Beneficiary must have Medicare Part B

– Billed to Part A MAC on CMS-1450/UB-04 claim form or electronic equivalent

• Professional services provided in PHP

– Beneficiary must have Medicare Part B

– Billed to Part B MAC on CMS-1500 claim form or electronic equivalent

(32)

PHP Billing Requirements –

Claim Forms and Form Locators

• Claim form UB-04/CMS-1450

• Complete all applicable claim fields of claim

form

– FL 1 through FL 80

• Many are self-explanatory such as – Beneficiary’s identifying information

– Provider’s identifying information

(33)

PHP Billing Requirements –

Claim Form and Form Locators

• CMS IOM Publication 100-04,

Medicare

Claims Processing Manual

, Chapter 25,

Section 75

– Each FL states ‘required’ or ‘situational’

• Required - CMS requires

(34)

PHP Billing Requirements –

Claim Form and Form Locators

Form Locator Definition

4 TOB

6 Statement covers period – claim’s from/through dates

17 PSC

18-28 CC

35-36 OSC with from/through date

(35)

PHP Billing Requirements –

Claim Form and Form Locators

Form Locator Description

44 HCPCS/Rates/HIPPS rate codes

45 LIDOS

46 Units of service

47 Total charges

48 Noncovered charges

67 Principal diagnosis code

(36)

PHP Billing Requirements –

Claim Form and Form Locators

• Claim codes are available from NUBC

(

http://www.nubc.org

) via NUBC’s Official

UB-04 Data Specifications Manual

(37)

PHP Billing Requirements - TOB

• Hospital outpatient

– TOB 13X

• CAH outpatient

– TOB 85X

• CMHC

(38)

PHP Billing Requirements – CC 41

• Hospitals & CAHs

– Report CC 41 on claims

• Indicates PHP services

• CMHCs

(39)

PHP Billing Requirements –

Revenue Codes and Charges

• Report revenue code(s) and associated

charge(s) for each individual service –

component billing

– Component billing assures that only those services covered under PHP benefit are paid

(40)

Acceptable Revenue Codes

Revenue Code Description

0250 Drugs & biologicals 043X Occupational therapy

0900 Behavioral health treatment/services 0904 Activity therapy

0914 Individual therapy 0915 Group therapy

0916 Family therapy 0918 Testing

(41)

PHP Billing Requirements –

CPT/HCPCS Codes

• HOPDs and CMHCs

– Report CPT/HCPCS codes

• CAHs

(42)

Acceptable CPT/HCPCS Codes

• CMHCs and hospitals other than CAHs are

also required to report appropriate HCPCS as

follows:

Revenue Code CPT/HCPCS Code(s)

043x G0129

0900 90791 or 90792 0904 G0176

0914 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865, or 90880 0915 G0410 or G0411

0916 90846 or 90847

0918 96101, 96102, 96103, 96116, 96118 , 96119, or 96120 0942 G0177

(43)

HCPCS Codes Definitions

• CMHCs and hospitals other than CAHs are

also required to report appropriate HCPCS as

follows:

HCPCS Code Definition

G0129

Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)

G0176

Activity therapy, such as music, dance, art or play therapies not for recreation, related to care and

treatment of patient’s disabling mental problems, per session (45 minutes or more)

(44)

HCPCS Codes Definitions

• CMHCs and hospitals other than CAHs are

also required to report appropriate HCPCS as

follows:

HCPCS Code Definition

G0177 Training and educational services related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more)

(45)

CPT Codes Definitions

• CMHCs and hospitals other than CAHs are

also required to report appropriate HCPCS as

follows:

CPT Code Definition

90791 Psychiatric diagnostic evaluation (no medical services) completed by a

nonphysician

90792 Psychiatric diagnostic evaluation (with

(46)

Did You Know…

• CR 8141 advised providers that several

revisions were made to the PHP billing

code set effective January 1, 2013.

(47)

Did You Know…

• Professional services of physicians and other practitioners provided in HOPDs (including

CAHs) for OP PHP patients are separately covered and billed to the Part B MAC

• The following direct professional services are not paid as PHP services:

– Physician services that meet criteria for payment on a fee schedule basis

– PA services

– NP and CNS services

(48)

PHP Billing Requirements –

Service Units

• Hospitals and CMHCs

– Report number of times service/procedure (as defined by CPT/HCPCS code) was performed

• CAHs

– Report number of times revenue code visit was performed

• Note: Service units not required for

(49)

Reporting Service Units – Example

• Patient received psychological testing – CPT

code 96100 (defined in one-hour intervals) for a total of three hours during one day

• Hospital and CMHC report

– Revenue code 0918, CPT code 96100 and 3 units

• CAH reports

– Revenue code 0918, 1 unit (leave CPT code FL blank)

(50)

PHP Billing Requirements –

LIDOS Reporting

• Hospitals (other than CAHs) and CMHCs

– Required to report LIDOS per revenue code line for PHP claims

– Each service/revenue code provided must be repeated on separate line – with specific DOS for each occurrence

(51)

LIDOS Reporting – Example

• Each service must be repeated on a separate line with specific DOS for every occurrence

• This example is for group therapy services provided twice during a billing period:

Revenue Code

HCPCS Code

Date of

Service Units

Total Charges 0915 G0176 20130101 1 $80.00 0915 G0176 20130115 2 $160.00

(52)

PHP Billing Requirements –

Diagnosis

• Report mental health diagnosis for PHP

patients

(53)

PHP Billing Requirements –

References

• CMS IOM Publication 100-04, Medicare Claims Processing Manual,

– Chapter 1, Section 50.2.3 (CMS will update per CR 8048)

– Chapter 4 Section 260

– Chapter 25, Section 75

• National Government Services LCD 26398 & SIA A45932 – LCD & Article for PHPs

– http://NGSMedicare.com > Coverage Determinations > Medical Policy Center

(54)

Payment – CMHC

• CMHC PHP APCs:

APC Group Title

0172 Level I Partial Hospitalization (3 services) for CMHCs

0173 Level II Partial Hospitalization (4 or more services) for CMHCs

(55)

Payment – Hospital

• Hospital-based PHP APCs:

APC Group Title

0175 Level I Partial Hospitalization (3 services) for hospital-based PHPs

0176 Level II Partial Hospitalization (4 or more services) for hospital-based PHPs

(56)

Payment – CAH

• Payment to CAHs made on reasonable

cost basis

(57)

Beneficiary Cost-Sharing

• Medicare Part B deductible and

coinsurance apply to PHP claims

(58)

Did You Know…

• Payment may be made for covered

diagnostic/therapeutic services furnished

by CSWs in a hospital outpatient setting.

• CSW services furnished under a PHP are

included in the PHP reimbursement rate.

• Other CSW services must be billed to the

Part B MAC on a CMS-1500 claim form.

(59)

Interim Billing

(60)

PHP Interim Billing

• CR 8048, “Enforcing Interim Billing for

PHP Services”

– Effective date 01/01/13

(61)

PHP Interim Billing

• Beginning 04/01/13, Medicare will enforce

interim billing of claims for PHP services

– Medicare requires that claims for PHP

services be submitted in DOS order (interim or sequential billing)

– Applies to TOBs:

• 13X (hospital outpatient) with CC 41

• 85X (CAH) with CC 41

(62)

Did You Know…

• In the CY 2013 Physician Fee Schedule final

rule, CMS created a new G-code that will be

used to report physician (or qualifying

nonphysician practitioner) care management

services for a patient following a discharge

from a PHP.

• Crucial to this implementation, is correct

interim billing of PHP services.

(63)

PHP Interim Billing –

Frequency Digit in TOB

• To determine out of sequence claim

submission for outpatient course of

treatment, provider must utilize correct

frequency digit in TOB

(64)

PHP Interim Billing –

Frequency Digit in TOB = “1”

• If from/through dates on claim include

dates for all services of course of

treatment

– Frequency digit in TOB is “1”

– Admit through discharge claim (i.e., 131, 761, or 851)

(65)

PHP Interim Billing –

Frequency Digit in TOB = “2”

• If from/through dates on claim include

DOS at start of course of treatment and

additional services are expected to be

submitted on a subsequent bill

– First interim claim (i.e., 132, 762, or 852) – PSC “30”

(66)

PHP Interim Billing –

Frequency Digit in TOB = “3”

• If from/through dates on claim include

services neither at start or completion of

course of treatment and additional

services are expected to be submitted on

a subsequent bill

– Interim continuing claim (i.e., 133, 763, or 853)

(67)

PHP Interim Billing –

Frequency Digit in TOB = “4”

• If from/through dates on claim include

DOS at completion of course of treatment

and no additional services are expected to

be submitted on a subsequent bill

– Interim last claim (i.e., 134, 764, or 854) – Final PSC

(68)

Did You Know…

• Providers may submit interim bills daily,

weekly, or monthly as long as the claims are

submitted with the correct frequency code in

the TOB and sequentially.

(69)

PHP Interim Billing – Other

Services Rendered During PHP

• LOA “carve out” process applies

– Continue to submit interim PHP claims even if non-PHP services rendered during non-PHP claim

from/through dates

• For example, inpatient stay, outpatient services, or outpatient service subject to OPPS

– Report OSC 74 on PHP claim with LOA dates

• From/through dates for when non-PHP services are provided during PHP claim from/through dates

– See example in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2.2

(70)

PHP Interim Billing –

Consistency Editing

• FISS will enforce consistency editing for

PHP services from hospitals, CAHs and

CMHCs

– To ensure that outpatient providers submit

claims for a continuing course of treatment for a patient in DOS sequence

• Bills submitted out of sequence will be

RTP

(71)

(72)

Resources

• CMS IOMs Web page

–

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html • Publication 100-02, Medicare Benefit Policy Manual

– Chapter 6, Section 70, 70.1 and 70.3

• Publication 100-04, Medicare Claims Processing Manual

– Chapter 1, Section 50.2.2 and 50.2.3

(73)

Resources

• CMS Transmittals Web page

–

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/index.html • CR 8141

–

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2611CP.pdf • CR 8048

–

(74)

Resources

• CMS Medlearn Matters Web page

– http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/

• MM8141

– http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/Downloads/MM8141.pdf • MM8048

– http://www.cms.gov/Outreach-and-Education/Medicare-

(75)

Resources

• National Government Services LCD 26398

& SIA A45932 – LCD & Article for PHPs

– http://NGSMedicare.com > Coverage Determinations > Medical Policy Center

(76)

Resources

• Mental Health Services Booklet ICN

903195, revised March 2012

–

http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Mental_Health _Services_ICN903195.pdf

(77)

What You Should Do Now…

• Share presentation with coworkers who could

not attend

• Submit claims in accordance with Medicare

coverage and billing guidelines

• Ensure proper interim billing

• Be familiar with resources

(78)

(79)

To Ask a Question

(80)

Web Site Survey

• This is your chance to have your voice

heard—Say “yes” when you see this

pop-up so National Government Services can

make your job easier!

(81)

Medicare University

• http://www.MedicareUniversity.com

• Interactive online system available 24/7

• Educational opportunities available

– Computer-based training courses

– Teleconferences, Webinars, live seminars/face-to-face training

(82)

Medicare University

Self-Reporting Instructions

• Log on to the National Government Services

Medicare University site at

http://www.NGSMedicare.com

– Topic = J13: Partial Hospitalization Program Interim Billing Guidelines

– Medicare University Credits (MUCs) = 2 – Catalog Number = Sent via e-mail

– Course Code = Sent via e-mail

– For step-by-step instructions on self-reporting please visit http://www.NGSMedicare.com > Medicare

(83)

Thank You!

• Follow-up e-mail

– We send to registered attendees following presentation

– Provides Medicare University Catalog Number and Course Code and requests completion of an online assessment

• Training summary

– Summary of session content and questions & answers – Posts to Web site within 30 days under Education &

Training > Training Summaries > Webinar Materials

• Questions?

– Questions in Webinar question box will now be addressed – Questions for which we do not have time will be responded

to in training summary along with questions already answered