MHCP PROVIDER MANUAL PARTIAL HOSPITALIZATION PROGRAM (CHAPTER 16

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MHCP Provider Manual - Partial Hospitalization Program (Chapter 16 — Overview Page)

Partial hospitalization is a time limited, structured program of multiple and intensive psychotherapy and other therapeutic services provided by a multidisciplinary team, as defined by Medicare, and provided in an outpatient hospital facility or community mental health center (CMHC) that meets Medicare requirements to provide partial hospitalization programs services. The goal of the partial hospitalization program is to resolve or stabilize an acute episode of mental illness.

 

Eligible Partial Hospitalization Providers

To be a partial hospitalization provider, an outpatient hospital or a CMHC must:

Be certified by Medicare to provide partial hospitalization
Receive approval from DHS

Providers must follow Medicare guidelines for partial hospitalization program content, physician certification requirements, and documentation.

 

Eligible Recipients

To receive partial hospitalization program services, a recipient must:

Be eligible for MA, GAMC or MinnesotaCare
Be experiencing an acute episode of mental illness that meets the criteria for an inpatient hospital admission
Have appropriate family or community resources needed to support and enable the recipient to benefit from less than 24-hour care
Be referred for partial hospitalization by a physician

Partial hospitalization may be beneficial to recipients transitioning out of inpatient mental health stays or in lieu of inpatient psychiatric.

 

Partial Hospitalization Covered Services

Partial hospitalization includes, at minimum, one session of individual, group or family psychotherapy and two or more other services (such as activity therapy or training and education).

To be consistent with Medicare recommended standards:

Provide at least 4 days but not more than 5 out of 7 calendar days of partial hospitalization program services
Ensure a minimum of 20 service components and a minimum of 20 hours in a 7 calendar day period
Provide a minimum of 5 to 6 hours of services per day for an adult age 18 years or over
Provide a minimum of 4 to 5 hours of services per day for a child under age 18 years

 

Billing

Use the MN-ITS 837I or UB-04 form to bill for partial hospitalization program services.

Indicate the patient status information as continuing service; indicating discharge instead of continuing service may deny the claim
Enter the type of bill (TOB) 13X Outpatient
Enter the type of bill (TOB), 76X Community Mental Health Center (CMHC)
Use revenue code 0912
Use revenue code 0913
Use procedure code H0035 or H0035 HA for children/adolescent services

Therapy outside the partial hospitalization program is covered only for physician services and medication management:

Bill using MN-ITS 837P or the CMS-1500 claim form
Bill visits using the appropriate E/M code
Enter place of service 22 (outpatient hospital) or 53 (CMHC)

If the purpose of the visit is to provide psychotherapy only or hybrid psychotherapy/E/M services, the appropriate psychotherapy codes require compliance with the authorization requirements.

 

Authorization Requirements

A recipient may receive up to 21 calendar days of partial hospitalization program services without authorization.

Submit an authorization request with supporting documentation of medical necessity for:

Services provided after the 21^st day (beginning the 22^nd day) following admission; Medicare guidelines require physician re-certification by the 18^th day
Providing fewer than five hours of partial hospitalization per day for an adult age 18 years or over; or fewer than four hours of partial hospitalization per day for a child under age 18 years (circumstances, such as when a recipient is unable to tolerate a full day, are rare that a recipient would require fewer or reduced services on any given day)
Readmission within 45 days of a previous discharge (most individuals will not experience a second acute episode of mental illness within 45 days of discharge from a partial hospitalization program)
An authorization may be needed when an Intensive Residential Treatment Services (IRTS) provider received payment for same day service as the PHP and the PHP was denied. Although an IRTS provider must seek prior authorization for providing intensive rehabilitative mental health services to a resident of the IRTS when the resident participates in a partial hospitalization program on the same day, claims are paid on a first in, first paid basis. If the PHP receives a denial for this reason, the partial provider should first contact the IRTS provider to coordinate care if not already in progress and submit a request to CDMI for authorization of the PHP for that day

 

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