Inpatient Hospital Care or PHP

Positive Changes CPT

Mid point of 30 min = 15 min of tx)
90833 – $60.83 (30 min psychotherapy)
99213 – $47.10
$107.93

Mid point of 30 min = 15 min of tx)
90833 – $60.83 (30 min psychotherapy)
99214 – $
$127.20

Mid point of 30 min = 15 min of tx)
90833 – $60.83 (30 min psychotherapy)
99215 – $
$156.47

CPT/HCPS for PHP Reimbursement

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

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

Primary Diagnosis

If services provided are for psychiatric services, the primary diagnosis must be psychiatric. Likewise, if services provided are for substance use disorder treatment, the primary diagnosis must be substance use disorder.

OHCA Policies and Rules – Part 21 Outpatient Behavioral Health

(5) Servicerequirements.

(A) Therapeutic Services are to include the following:

(i) Psychiatrist/physician face-to-face visit two (2) times per month;

(ii) Crisis management services available twenty-four (24) hours a day, seven (7) days a week;

(B) Psychotherapies to be provided a minimum of four (4) hours per week and include the following:

(i) Individual therapy – a minimum of one (1) session per week;

(ii) Family therapy – a minimum of one (1) session per week; and

(iii) Group therapy – a minimum of two (2) sessions per week;

(C) Interchangeable services which include the following:

(i) Behavioral Health Case Management (face-to-face);

(ii) Behavioral health rehabilitation services/alcohol and other drug abuse education except for children under age six (6), unless a prior authorization has been granted for children ages four (4) and five (5);

(iii) Medication Training and Support; and

(iv) Expressive therapy.

(6) Documentation requirements.  Documentation needs to specify active involvement of the member’s family, caretakers, or significant others involved in the individual’s treatment. A nursing health assessment must be completed within twenty-four (24) hours of admission. A physical examination and medical history must be coordinated with the Primary Care Physician. Service plan updates are required every three (3) months or more frequently based on clinical need. Records must be documented according to OAC 317:30-5-248.

(7) Staffing requirements.  Staffing requirements must consist of the following:

(A) RN trained and competent in the delivery of behavioral health services as evidenced by education and/or experience that is available onsite during program hours to provide necessary nursing care and/or psychiatric nursing care [one (1) RN at a minimum can be backed up by an LPN but an RN must always be onsite]. Nursing staff administers medications, follows up with families on medication compliance, and restraint assessments.

(B) Medical director must be a licensed psychiatrist.

(C) A psychiatrist/physician must be available twenty-four (24) hours a day, seven (7) days a week.

(f) Children/Adolescent Day Treatment Program.

(1) Definition.  Day Treatment Programs are for the stabilization of children and adolescents with severe emotional and/or behavioral disturbances. Treatment is designed for children who have difficulty functioning in mainstream community settings such as classrooms, and who need a higher intensity of services than outpatient counseling provides. Treatment is time limited and includes therapeutically intensive clinical services geared towards reintegration to the home, school, and community.

(2) Qualified practitioners.  All services in Day Treatment are provided by a team, which must be composed of one (1) or more of the following participants: physician, registered nurse, licensed behavioral health professional (LBHP) or licensure candidate, a case manager, or other certified Behavioral Health/Substance Abuse paraprofessional staff. Services are directed by an LBHP or licensure candidate.

(3) Qualified providers.  Provider agencies for Day Treatment must be accredited to provide Day Treatment services by one of the national accrediting bodies; The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), Accreditation Commission for Health Care (ACHC) or The Council on Accreditation (COA).

(4) Limitations.  Services must be offered at a minimum of four (4) days per week at least three (3) hours per day. Behavioral Health Rehabilitation Group size is limited to a maximum of eight (8) individuals as clinically appropriate given diagnostic and developmental functioning. Children under age six (6) are not eligible for behavioral health rehabilitation services, unless a prior authorization for children ages four (4) and five (5) has been granted by OHCA or its designated agent based on a finding of medical necessity.

(5) Service requirements.  On-call crisis intervention services must be available twenty-four (24) hours a day, seven (7) days a week (When members served have psychiatric needs, psychiatric services are available which include the availability of a psychiatrist twenty-four (24) hours a day, seven (7) days a week. A psychiatrist can be available either on site or on call but must be available at all times). Day treatment program will provide assessment and diagnostic services and/or medication monitoring, when necessary.

(A) Treatment activities are to include the following every week:

(i) Family therapy at least one (1) hour per week (additional hours of FT may be substituted for other day treatment services);

(ii) Group therapy at least two (2) hours per week; and

(iii) Individual therapy at least one (1) hour per week.

(B) Additional services are to include at least one (1) of the following services per day:

(i) Medication training and support (nursing) once monthly if on medications;

(ii) Behavioral health rehabilitation services to include alcohol and other drug education if the child meets the criteria established in OAC 317:30-5-241.3 and is clinically necessary and appropriate except for children under age six (6), unless a prior authorization has been granted for children ages four (4) and five (5);

(iii) Behavioral health case management as needed and part of weekly hours for member;

(iv) Occupational therapy as needed and part of weekly hours for member; and

(v) Expressive therapy as needed and part of weekly hours for the member.

(6) Documentation requirements.  Service plans are required every three (3) months.

PHP Billing Guidelines

Freestanding PHPs and Outpatient Prospective Payment System (OPPS) – Exempt Hospital-Based PHPs

These facilities are reimbursed under the PHP per diem payment methodology outlined in the TRICARE Reimbursement Manual, Chapter 7, Section 2.

These facilities must be billed on a UB-04 with one of the following:

1. Revenue code 912 for: 
   • Psychiatric Partial Hospitalization – all-inclusive per diem payment of three to five hours (half day); or
   • Substance Use Disorder Partial Hospitalization – all-inclusive per diem payment of three to five hours (half day)
2. Revenue code 913 for: 
   • Psychiatric Partial Hospitalization – all-inclusive per diem payment of six or more hours (full day); or
   • Substance Use Disorder Partial Hospitalization – all inclusive per diem payment of six or more hours (full day)

Note: Revenue codes must be billed separately for each date of service.

Professional provider services furnished by clinical social workers, occupational therapists and alcohol and addiction counselors are included in the PHP per diem payment whether the providers are employed or contracted by the PHP.