Partial Hospitalization Program and services


Partial Hospitalization Services 

Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in §1861(ff) of the Social Security Act (the Act). The treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. Programs providing primarily social, recreational, or diversionary activities are not considered partial hospitalization.

A. Program Criteria.--PHPs work best as part of a community continuum of mental health services which range from the most restrictive inpatient hospital setting to less restrictive outpatient care and support. Program objectives should focus on ensuring important community ties and closely resemble the real-life experiences of the patients served. PHPs may be covered under Medicare when they are provided by a hospital outpatient department or a Medicarecertified CMHC. Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.

A program comprised primarily of diversionary activity, social, or recreational therapy does not constitute a PHP. Psychosocial programs which provide only a structured environment, socialization, and/or vocational rehabilitation are not covered by Medicare. A program that only monitors the management of medication for patients whose psychiatric condition is otherwise stable, is not the combination, structure, and intensity of services which make up active treatment in a PHP.

B. Patient Eligibility Criteria.--

1. Benefit Category.--Patients must meet benefit requirements for receiving the partial hospitalization services as defined in §1861(ff) and §1835(a)(2)(F) of the Act. Patients admitted to a PHP must be under the care of a physician who certifies the need for partial hospitalization. The patient requires comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning. Such dysfunction generally is of an acute nature.

Patients meeting benefit category requirements for Medicare coverage of a PHP comprise two groups: those patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment; or those patients who, in the absence of partial hospitalization, would be at reasonable risk of requiring inpatient hospitalization. Where partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP. Recertification must address the continuing serious nature of the patients psychiatric condition requiring active treatment in a PHP. Discharge planning from PHP may reflect the types of best practices recognized by professional and advocacy organizations that ensure coordination of needed services and follow-up care.

These activities include linkages with community resources, supports, and providers in order to promote a patient’s return to a higher level of functioning in the least restrictive environment.

2. Covered Services.--Items and services that can be included as part of the structured, multimodal active treatment program, identified in §1861(ff)(2) include:

• Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);

• Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;

• Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;

• Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);

• Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;

• Family counseling services for which the primary purpose is the treatment of the patient’s condition;

• Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and

• Medically necessary diagnostic services related to mental health treatment. Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial. It is not enough that a patient qualify under the benefit category requirements §1835(a)(2)(F) unless he/she also has the need for the active treatment provided by the program of services defined in §1861(ff). It is the need for intensive, active treatment of his/her condition to maintain a functional level and to prevent relapse or hospitalization, which qualifies the patient to receive the services identified in §1861(ff).

 3. Reasonable and Necessary Services.--This program of services provides for the diagnosis and active, intensive treatment of the individual’s serious psychiatric condition and, in combination, are reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization. A particular individual covered service (described above) as intervention, expected to maintain or improve the individual’s condition and prevent relapse, may also be included within the plan of care, but the overall intent of the partial program admission is to treat the serious presenting psychiatric symptoms. Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive outpatient, psychosocial, day  treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent hospitalization.

Patients admitted to a PHP do not require 24 hour per day supervision as provided in an inpatient setting, and must have an adequate support system to sustain/maintain themselves outside the PHP. Patients admitted to a PHP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5 of the most current edition of the International Classification of Diseases (ICD), which severely interferes with multiple areas of daily life. The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from participating in an active treatment program. It is the need, as certified by the treating physician, for the intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patient’s presenting psychiatric condition.

For patients who do not meet this degree of severity of illness, and for whom partial hospitalization services are not necessary for the treatment of a psychiatric condition, professional services billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even though partial hospitalization services are not. Patients in PHP may be discharged by either stepping up to an inpatient level of care which would be required for patients needing 24-hour supervision, or stepping down to a less intensive level of outpatient care when the patient’s clinical condition improves or stabilizes and he/she no longer requires structured, intensive, multimodal treatment.

4. Reasons for Denial.--

a. Benefit category denials made under §1861(ff) or §1835(a)(2)(F) are not appealable by the provider and the limitation on liability provision does not apply (HCFA Ruling 97-1). Examples of benefit category based in §1861(ff) or §1835(a)(2)(F) of the Act, for partial hospitalization services generally include the following:
• Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
• Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
• Patients who are otherwise psychiatrically stable or require medication management only.

b. Coverage denials made under §1861(ff) of the Act are not appealable by the provider and the Limitation on Liability provision does not apply (HCFA Ruling 97-1). The following services are excluded from the scope of partial hospitalization services defined in §1861(ff) of the Social Security Act:
• Services to hospital inpatients;
• Meals, self-administered medications, transportation; and
• Vocational training.

c. Reasonable and necessary denials based on §1862(a)(1)(A) are appealable  and the Limitation on Liability provision does apply. The following examples represent reasonable and necessary denials for partial hospitalization services and coverage is excluded under §1862(a)(1)(A) of the Social Security Act:

• Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or

• Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.

5. Documentation Requirements and Physician Supervision.--The following  components will be used to help determine whether the services provided were accurate and appropriate.


Partial Hospitalization Program (PHP) is a non-24-hour diversionary treatment program that is hospital-based or community-based. The program provides diagnostic and clinical treatment services on a level of intensity similar to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu; nursing; psychiatric evaluation; medication management; individual, group, and family therapy; peer support and/or other recovery-oriented services; substance use disorder evaluation and counseling; and behavioral plan development.

The environment at this level of treatment is highly structured, and there is a staff-to-Member ratio sufficient to ensure necessary therapeutic services, professional monitoring, and risk management. PHP may be appropriate when a Member does not require the more restrictive and intensive environment of a 24-hour inpatient setting but does need up to eight hours of clinical services, multiple days per week. PHP is used as a time-limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care, such as a step-down from inpatient services, as well as a stand-alone, diversionary level of care to stabilize a Member’s deteriorating condition, support him/her in remaining in the community, and avert hospitalization. Treatment efforts focus on the Member’s response during treatment program hours, as well as the continuity and transfer of treatment gains during the Member’s non-program hours in the home/community.

Components of Service

1. The provider complies with all provisions of the corresponding section in the General performance specifications.

2. The PHP offers short-term day programming consisting of therapeutically intensive, acute treatment within a stable therapeutic milieu. A psychiatrist oversees medication management and daily active treatment, as described within the Process Specifications section.

3. Full therapeutic programming is provided five days per week, with sufficient professional staff to conduct these services and to manage a therapeutic milieu. The scope of required service components provided in this level of care includes, but is not limited to, the following. Please refer to the per diem/service definition which is all-inclusive and includes the components covered in the rate for this service,

a. Bio-psychosocial evaluation
b. Psychiatric evaluation
c. Medical history
d. Physical examination/medical assessment (to assess for medical issues)
e. Pharmacology
f. Nursing assessment and services, or similar service provided by the program’s MD staffing
g. Individual, group, and family therapy
h. Case and family consultation
i. Peer support and/or other recovery-oriented services
j. Substance use disorder assessment and counseling
k. Development of behavioral plans and crisis prevention plans, and/or  safety plans as part of the Crisis Planning Tools for youth, as applicable

4. For minor children and for adults who give consent, the provider makes documented attempts to contact the parent, guardian, family members, and/or significant others within 48 hours of admission, unless clinically or legally contraindicated. The provider provides them with all relevant information related to maintaining contact with the program and the Member, including names and phone numbers of key nursing staff, primary treatment staff, social worker/care coordinator/discharge planner, etc. If contact is not made, the Member’s health record documents the rationale.

5. The provider engages in a medication reconciliation process in order to avoid inadvertent inconsistencies in medication prescribing that may occur in transition of a Member from one care setting to another. The provider does this by reviewing the Member’s complete medication regimen at the time of admission (e.g., transfer and/or discharge from another setting or prescriber), and comparing it with the regimen being considered in the PHP. The provider engages in the process of comparing the Member’s medication orders newly issues by the PHP to all of the medications that he/she has been taking in order to avoid medication errors. This involves:
a. developing a list of current medications, i.e., those the Member was prescribed prior to admission to the PHP;
b. developing a list of medications to be prescribed in the PHP;
c. comparing the medications on the two lists;
d. making clinical decisions based on the comparison and, when indicated, in coordination with the Member’s primary care clinician (PCC); and

e. communicating the new list to the Member and, with consent, to appropriate caregivers, the Member’s PCC, and other treatment providers. All related activities are documented in the Member’s health record.

6. If a Member experiencing a behavioral health crisis contacts the provider, during business hours or outside business hours, the provider, based on his/her assessment of the Member’s needs and under the guidance of his/her supervisor, may: 1) offer support and intervention through the services of the PHP program, during business hours; 2) implement interventions to support the Member and enable him/her to remain in the community, when clinically appropriate, e.g., highlight elements of the Member’s crisis prevention plan and/or safety plan, encourage implementation of the plan, offer constructive, step-by-step strategies which the Member may apply, and/or follow-up and assess the safety of the Member and other involved parties, as applicable; 3) refer the Member to his/her outpatient provider; and/or 4) refer the Member to an ESP/MCI for emergency behavioral health crisis assessment, intervention, and stabilization.

a. Outside business hours, the provider offers telephonic coverage. An  answering machine or answering service directing callers to call911, call the nearest ESP/MCI, or to go to a hospital emergency department (ED), does not meet the after-hours on-call requirements.

Staffing Requirements

1. The provider complies with all provisions of the corresponding section in the General performance specifications.

2. The provider complies with the staffing requirements of the applicable licensing body, the staffing requirements in the MBHP service-specific  performance specifications, and the credentialing criteria outlined in the MBHP Provider Manual, Volume I, as referenced at www.masspartnership.com.

3. The staff includes a PHP Director or Supervisor who is an independently licensed, master’s-level or doctoral-level clinician. He/she is responsible for the clinical oversight and quality of care within the PHP, in collaboration with the medical director, and ensures the provision of all PHP service components. He/she is available for consultations regarding emergency or urgent situations.

4. The PHP has a written staffing plan that delineates the number and credentials of its professional staff, including an attending psychiatrist(s), nurses, social workers, and other mental health professionals to ensure that all required services are provided and performance specifications are met.

The Program Director or Supervisor collaborates with the medical director on the development and maintenance of the staffing plan for psychiatry.

5. Members have access to supportive milieu and clinical staff throughout the PHP hours of operation.

6. The provider has adequate psychiatric coverage to ensure all performance specifications related to psychiatry are met.

7. The provider appoints a medical director who is fully integrated into the administrative and leadership structure of the PHP and is responsible for clinical and medical oversight, quality of care, and clinical outcomes across all PHP service components, in collaboration with the PHP Director or Supervisor and the clinical leadership team.

a. The medical director is a psychiatrist who is board-certified and/or who meets MBHP’s credentialing criteria (Note: MBHP’s credentialing criteria for psychiatrists states that they must be boardcertified in general psychiatry by the American Board of Psychiatry and Neurology (ABPN) within two years of contracting with MBHP unless a waiver of this requirement is requested and received within two years of contracting with MBHP).

b. For providers with PHP programs for children and/or adolescents: If the medical director is not a child/adolescent psychiatrist, the provider appoints a staff psychiatrist to have the primary responsibility to assess and evaluate children and adolescents, one who is board-certified in general psychiatry and child fellowshiptrained and/or board-certified in child/adolescent psychiatry and/or who meets MBHP’s credentialing criteria for a child/adolescent psychiatrist.

c. The medical director’s role may include the provision of direct psychiatry services and also includes:
i. attendance at multi-disciplinary team meetings at least weekly;
ii. teaching, training, coaching, and consulting with the multidisciplinary team; and
iii. oversight and monitoring of prescribing clinicians.
d. The medical director’s role also includes the following functions, in collaboration with the PHP Director or Supervisor and clinical leadership team:
i. Integration of the various assessments of the Member’s needs and strengths into a coherent narrative that can be used for treatment planning within the PHP and in the Member’s home and community;
ii. Development and utilization of the PHP’s unifying theory of treatment to guide its mission, vision, and practice;
iii. Development of therapeutic programming; and
iv. Ensuring that programs remain family-centered, and, for programs serving youth, child-focused.

e. For providers with PHPs for children and/or adolescents, the medical director ensures psychiatric practice consistent with the best available evidence-based practices and parameters developed by the American Academy of Child and Adolescent Psychiatry (AACAP) when evaluating and treating youth with complex needs and/or medication regimens, e.g., when Members attending the program are on multiple psychiatric medications, or are in the custody of a state agency and are starting or continuing atypical antipsychotics. The medical director monitors this practice through oversight and supervision.

8. The provider assigns an attending psychiatrist to each Member.
a. For children and adolescents under the age of 14, the attending psychiatrist is one who meets MBHP’s credentialing criteria for a child/adolescent psychiatrist.

9. Psychiatric care is provided by the medical director and/or other psychiatrists who are board-certified and/or who meet MBHP’s credentialing criteria. Psychiatric care consists of the provision of psychiatric and pharmacological assessment and treatment to Members in the PHP. The program may also utilize a psychiatry fellow/trainee to provide psychiatric services, under the supervision of the medical director or another attending psychiatrist, in conformance with the Accreditation Council for Graduate Medical Education (ACGME), and in compliance with all Centers for Medicare and Medicaid Services (CMS) guidelines for supervision of trainees by attending physicians. The program may also utilize a psychiatric nurse mental health clinical specialist (PNMHCS) to provide psychiatric services, within the scope of their licenses and under the supervision of the medical director, as outlined within these performance specifications. The program may also utilize a psychiatric resident to provide psychiatric services, under the supervision of the medical director or another attending psychiatrist.

10. For PHPs that utilize a PNMHCS for medication management within their license and scope of practice, all of the following apply:

a. There is documented maintenance of: a collaborative agreement between the PNMHCS and the medical director; and a consultation log including dates of consultation meetings and list of all Members reviewed. The agreement specifies whether the PNMHCS or the medical director will be responsible for this documentation;

b. The supervision/consultation between the PNMHCS and the medical director is documented and occurs at least one (1) hour per week for PNMHCS staff, or at a frequency proportionate to the hours worked for those PNMHCS staff who work less than full-time. The format may be individual, group, and/or team meetings;

c. A documented agreement exists between the medical director and the PNMHCS outlining how the PNMHCS can access the medical director when needed for additional consultation;

d. The medical director, or another psychiatrist, is the attending psychiatrist for the Member when a PNMHCS is utilized to provide direct psychiatry services to a given Member. The PNMHCS is not the attending for any Member; and e. There is documented active collaboration between the medical director and the PNMHCS relative to Members’ medication regimens, especially those Members for whom a change in their regimen is being considered.

11. For PHPs that utilize a psychiatry fellow/trainee for medication management, all of the following apply:



Partial Hospitalization Program (Adult)

Partial hospitalization is a nonresidential treatment program that may or may not be hospital-based. The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse evaluation and counseling, and behavioral plans. The environment at this level of treatment is highly structured, and there should be a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, control and protection. Psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting, but does need up to eight hours of clinical services. Partial hospitalization is used as a time-limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Treatment efforts need to focus on the individual's response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual's non-program hours in the home/community. Psychiatric partial hospital treatment is separate and distinct from psychiatric social rehabilitation programs or day treatment programs, which also focus on maximizing an individual’s level of functioning (e.g., self-sufficiency, communication skills, social support network), but are usually less psychiatrically-based, located in a community setting, and focus more on the development or enhancement of an individual’s coping skills necessary for daily social and occupational functioning. .Family involvement from the beginning of treatment is important unless contraindicated. Frequency should occur based on individual needs. 


Admission Criteria All of the following criteria are necessary for admission:

1. The individual demonstrates symptomatology consistent with a DSM-IV-TR (AXES I-V) diagnosis that requires and can reasonably be expected to respond to therapeutic intervention. Evaluation needs to include an assessment of substance abuse issues.

2. There is evidence of patient’s capacity and support for reliable attendance at the partial hospital program.

3. There is an adequate social support system available to provide the stability necessary for maintenance in the program OR the individual demonstrates willingness to assume responsibility for his/her own safety outside program hours.

4. There may be a risk to self, others, or property (e.g.. inability to undertake selfcare; mood, thought or behavioral disorder interfering significantly with activities of daily living; suicidal ideation or non-intentional threats or gestures; risk-taking or other self-endangering behavior) which is not so serious as to require 24-hour medical/nursing supervision, but does require structure and supervision for a significant portion of the day and family/community support when away from the partial hospital program.

5. The patient’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment, including routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property.

6. The treatment plan needs to clearly state what benefits the individual can reasonably expect to receive in program; the goals of treatment cannot be based solely on need for structure and lack of supports.


Psychosocial, Occupational, and Cultural and

Linguistic Factors

These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care decisions.


Exclusion Criteria Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service is required.
2. The individual does not voluntarily consent to admission or treatment or does not meet criteria for involuntary admission to this level of care.
3. The individual has medical conditions or impairments that would prevent beneficial utilization of services.
4. The individual exhibits a serious and persistent mental illness consistent throughout time and is not in an acute exacerbation of the mental illness;
5. The individual requires a level of structure and supervision beyond the scope of the program (e.g., considered a high risk for non-compliant behavior and/or elopement).
6. The individual can be safely maintained and effectively treated at a less intensive level of care
7. The primary problem is social, economic (i.e. housing, family conflict, etc.), or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration.
8. The focus of treatment is not primarily for peer socialization and group support.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:
1. The individual’s condition continues to meet admission criteria at this level of care;
2. The multi-disciplinary discharge planning process starts from the assessment and tentative plan upon admission, and includes the patient and family/significant other as appropriate
3. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
4. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement unless contraindicated. Family sessions as appropriate need to occur in a timely manner. Expected benefits from all relevant modalities, including family and group treatment, are documented.
5. All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice.
6. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident.
7. Care is rendered in a clinically appropriate manner and focused on individual’s behavioral and functional outcomes as described in the discharge plan.
8. When medically necessary, appropriate psychopharmacological intervention has
been prescribed and/or evaluated.
9. Patient is actively participating in treatment.
10. Co-ordination with relevant outpatient providers should be implemented.

Discharge Criteria Any of the following criteria are sufficient for discharge from this level of care:

1. The individual’s documented treatment plan, goals and objectives have been substantially met or a safe, continuing care program can be arranged and deployed at a lower level of care
2. The individual no longer meets admission criteria, or meets criteria for a less or more intensive level of care.
3. The individual, family, guardian and/or custodian are competent but nonparticipatory in treatment or in following the program rules and regulations. Nonparticipation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address nonparticipation issues. In addition, either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment.
4. Consent for treatment is withdrawn, and it is determined that the individual has the capacity to make an informed decision and does not meet criteria for an inpatient level of care.
5. Support systems, which allow the individual to be maintained in a less restrictive treatment environment, have been thoroughly explored and/or secured.
6. The patient is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite treatment planning changes
7. There is a discharge plan with follow-up appointments in place prior to discharge.




Patient discharge status code List and Definition


Patient Discharge Status Code - Definition

A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter (this could be a visit or an actual inpatient stay) or at the time end of a billing cycle (the  ‘through' date of a claim).


Q: Can Patient Discharge Status Code 30, Still a Patient, be used on both inpatient and outpatient claims?

A: Yes, it can be used on both types of claims. Patient Discharge Status Code 30 should be used on inpatient claims when billing for leave of absence days, and for inpatient and outpatient interim bills. The primary method to identify that the patient is still receiving care is the bill type frequency code (e.g., Frequency Code 2: Interim - First Claim, or Frequency Code 3: Interim - Continuing Claim) Bill types ending in 2 or 3 should be reported with patient status of 30.



Key Points on Discharge status codes

• MLN Matters® article SE0801 is provided to assist providers in determining the right discharge status code to use with their claims.

• Assigning the correct patient discharge status code is just as important as any other coding used when filing a claim. The same processes should be applied for patient discharge status codes as with any other coding.

• Choosing the patient discharge status code correctly avoids claim errors and helps you receive payment for your claim sooner.

• A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter (this could be a visit or an actual inpatient stay) or at the time end of a billing cycle (the ‘through' date of a claim).

• The Centers for Medicare & Medicaid Services (CMS) requires patient discharge status codes for:

• Hospital Inpatient Claims (type of bills (TOBs) 11X and 12X);

• Skilled Nursing Claims (TOBs 18X, 21X, 22X and 23X);

• Outpatient Hospital Services (TOBs 13X, 14X, 71X, 73X, 74X, 75X, 76X and 85X); and

• All Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X and 82X).

• It is important to select the correct patient discharge status code. In cases in which two or more patient discharge status codes apply, providers should code the highest level of care known.

• Omitting a code or submitting a claim with an incorrect code is a claim billing error and could result in the provider's claim being rejected or their claim being cancelled and payment being taken back.

• Applying the correct code will help assure that the providers receive prompt and correct payment. Patient Discharge Status Codes and Their Appropriate Use

Discharge status code list

01- Discharge to Home or Self Care (Routine Discharge)
• This code includes discharge to home; jail or law enforcement; home on oxygen if durable medical equipment (DME) only; any other DME only; group home, foster care, and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs; assisted living facilities that are not state-designated.


02 - Discharged/Transferred to a Short Term General Hospital for Inpatient Care
• This patient discharge status code should be used when the patient is discharged or transferred to a short-term acute care hospital. Discharges or transfers to long-term care hospitals (LTCHs) should be coded with Patient discharge status Code 63.

03 - Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care
• This code indicates that the patient is discharged/transferred to a Medicare-certified nursing facility in anticipation of skilled care. For hospitals with an approved swing bed arrangement, providers should use Code 61- Swing Bed.
• This code should be used regardless of whether or not the patient has skilled benefit days and regardless of whether the transferring hospital anticipates that this SNF stay will be covered by Medicare.
• For reporting other discharges/transfers to nursing facilities, providers should see codes 04 and 64.
• Code 03 should not be used if the patient is admitted to a non-Medicare certified area.


04 - Discharged/Transferred to an Intermediate Care Facility (ICF)
• Patient discharge status code 04 is typically defined at the state level for specifically designated
intermediate care facilities. It is also used:
• To designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification, or
• For discharges/transfers to state designated Assisted Living Facilities.

05 - Discharged/Transferred to Another Type of Health Care Institution Not Defined Elsewhere in This Code List
• Cancer hospitals excluded from Medicare Prospective Payment System (PPS) and children’s hospitals are examples of such other types of health care institutions. New Definition for Patient Discharge Status Code 05 - Effective, per National Uniform Billing Committee (NUBC), on April 1, 2008:

• 05 - Discharged/Transferred to a Designated Cancer Center or Children’s Hospital Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list of (National Cancer Institute) Designated Cancer Centers can be found at http://cancercenters.cancer.gov/cancer_centers/cancer-centers-names.html on the Internet.


06 - Discharged/Transferred to Home Under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care

• This code should be reported when a patient is:
• Discharged/transferred to home with a written plan of care for home care services (tailored to the patient’s medical needs) -- whether home attendant, nursing aides, certified attendants, etc.;
• Discharged/transferred to a foster care facility with home care; and
• Discharged to home under a home health agency with durable medical equipment (DME).
• This code should not be used for home health services provided by a:
• DME supplier or
• Home IV provider for home IV services.


07 - Left Against Medical Advice or Discontinued Care
• The important thing to remember about this patient discharge status code is that it is to be used when a patient leaves against medical advice or the care is discontinued. According to the NUBC, discontinued services may include:
• Patients who leave before triage, or are triaged and leave without being seen by a physician; or
• Patients who move without notice, and the home health agency is unable to complete the plan of care.


08 - Reserved for National Assignment
• This patient discharge status code is reserved for national assignment.

09 - Admitted as an Inpatient to this Hospital
• This code is for use only on Medicare outpatient claims, and it applies only to those Medicare outpatient services that begin greater than three days prior to an admission.

10-19 - Reserved for National Assignment
• These patient discharge status codes are reserved for national assignment. 20 - Expired
• This code is used only when the patient dies.

21-29 - Reserved for National Assignment
• These patient discharge status codes are reserved for national assignment.


30 - Still Patient or Expected to Return for Outpatient Services
• This code is used when the patient is still within the same facility and is typically used when billing for leave of absence days or interim bills. It can be used for both inpatient or outpatient claims.
• It is used for inpatient claims when billing for leave of absence days or interim billing (i.e., the length of stay is longer than 60 days).
• On outpatient claims, the primary method to identify that the patient is still receiving care is the bill type frequency code (e.g., Frequency Code 3: Interim - Continuing Claim).

31-39 - Reserved for National Assignment
• These patient discharge status codes are reserved for national assignment.

40 - 42 Hospice Patient discharge status Codes - Hospice Claims Only (TOBs: 81X & 82X)
• The following patient discharge status codes should only be used when submitting hospice claims:
• 40 - Expired at Home - This code is for use only on Medicare and TRICARE claims for hospice care;
• 41 - Expired in a Medical Facility, such as a hospital, SNF, ICF, or free-standing hospice; and
• 42 - Expired - Place Unknown; This code is for use only on Medicare and TRICARE claims for hospice care.

43 - Discharged/Transferred to a Federal Hospital
• This code applies to discharges and transfers to a government operated health care facility including:
• Department of Defense hospitals;
• Veteran's Administration hospitals; or
• Veteran's Administration nursing facilities.
• This patient discharge status code should be used whenever the destination at discharge is a federal health care facility, whether the patient resides there or not.
• The NUBC has also clarified that this code should also be used when a patient is transferred to an inpatient psychiatric unit of a Veterans Administration hospital.

44-49 Reserved for National Assignment
• These patient discharge status codes are reserved for national assignment. 50 and 51 - Discharged/Transferred to a Hospice
• These two patient discharge status codes are used to identify when a patient is discharged or transferred to hospice care.
• The level of care that will be provided by the hospice upon discharge is essential to determining the proper code to use.
• NUBC clarified the following Hospice Levels of Care:
• Routine or Continuous Home Care - Patient discharge status code “50: Hospice home” should be used if the patient went to his/her own home or an alternative setting that is the patient’s “home,” such as a nursing facility, and will receive in-home hospice services;

• General Inpatient Care - Patient discharge status code “51: Hospice medical facility” should  be used if the patient went to an inpatient facility that is qualified and the patient is to receive the general inpatient hospice level of care; and

• Inpatient Respite - Patient discharge status code “51: Hospice medical facility” should be used if the patient went to a facility that is qualified and the patient is receiving hospice inpatient respite level of care. Unless a patient has already been admitted to/accepted by a hospice, level of care cannot be determined. Therefore, it is recommended that if a patient is going home or to an institutional setting with a hospice “referral only” (without having already been accepted for hospice care by a hospice organization), the patient discharge status code should simply reflect the site to which the patient was discharged; not hospice (i.e., 01: home or self care, or 04: an intermediate care nursing facility, assuming it is not a Medicare SNF admission).

Additional Guidance on Use of Patient discharge status Code 50 or 51

• Patient discharge status Code 50 should be used if the patient went to his/her own home or an alternative setting that is the patient’s “home,” such as a nursing facility, and will receive in-home hospice services.
• Patient discharge status Code 51 should be used when a patient is:
• Discharged from acute hospital care but remains at the same hospital under hospice care,
• Transferred from an inpatient acute care hospital to a Medicare-certified SNF under the following conditions:
• The patient has elected the hospice benefit and will be receiving hospice care under arrangement with a hospice organization; the patient is receiving residential care only;
• The patient does not qualify for skilled level of care outside the hospice benefit for conditions unrelated to the terminal illness; and
• The patient is admitted from home (a private residence) to an acute setting. Upon discharge, the patient is transferred as a new nursing home placement to a designated hospice unit/bed.

52-60 - Reserved for National Assignment
• These patient discharge status codes are reserved for national assignment.

61 - Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed
• This code is used for reporting patients discharged/transferred to a SNF level of care within the hospital’s approved swing bed arrangement.
• When a patient is discharged from an acute hospital to a Critical Access Hospital (CAH) swing bed, use patient discharge status code 61. Swing beds are not part of the post acute care transfer policy

62 - Discharged/Transferred to an Inpatient Rehabilitation Facility Including Distinct Part Units of a Hospital
• Inpatient rehabilitation facilities (or designated units) are those facilities that meet a specific requirement that 75% of their patients require intensive rehabilitative services for the treatment of certain medical conditions. This code should be used when a patient is transferred to a facility or designated unit that meets this qualification.

63 - Discharged/Transferred to Long Term Care Hospitals (LTCHs)
• This code is for hospitals that meet the Medicare criteria for LTCH certification. LTCHs are facilities that provide acute inpatient care with an average length of stay of 25 days or greater.
• This code should be used when transferring a patient to a LTCH.
• If providers are not sure whether a facility is a LTCH or a short-term care hospital, they should contact the facility to verify their facility type before assigning a patient discharge status code.


64 - Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not Certified Under Medicare
• Nursing facilities may elect to certify only a portion of their beds under Medicare, and some nursing facilities choose to certify all of their beds under Medicare. Still others elect not to certify any of their beds under Medicare.
• When a patient is transferred to a nursing facility that has no Medicare certified beds, this code should be used. If any beds at the facility are Medicare certified, then the provider should use either patient discharge status code 03 or 04, depending on:
• The level of care the patient is receiving; and
• Whether the bed is Medicare certified or not.


65 - Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital
• This code should be used when a patient is transferred to an inpatient psychiatric unit or inpatient psychiatric designated unit.
Note: This code should not be used when a patient is transferred to an inpatient psychiatric unit of a federal hospital (e.g., Veterans Administration Hospitals). In this case, see Patient discharge status Code 43.


66 - Discharged/Transferred to a CAH
• Patient discharge status Code 66 is used to identify a transfer to a critical access hospital (CAH) for inpatient care. Providers will need to establish a process for identifying whether a hospital is paid under the PPS or whether the facility is designated as a CAH.
Nor transfers to a CAH swing bed should still be coded with Patient discharge status Code 61.





Correction to Patient Discharge Status Codes in Medicaid Providers Manual Information posted February 1, 2013

This is a correction to the Texas Medicaid Provider Procedures Manual (TMPPM), Volume 1, General Information, subsection 6.6.6, “Patient Discharge Status Codes.” The table in this subsection in the December 2012 and January 2013 editions of the TMPPM has the following errors:
• The table included patient discharge status codes that are not available in the TMHP claims processing system:
o 21 – Discharged/transferred to court/law enforcement
o 70 – Discharged/transferred to another type of health-care institution not defined elsewhere in the patient discharge status code table
• The table omitted patient status discharge codes that continue to be valid in the TMHP claims processing system:
o 71 – Discharge to another institution of outpatient services
o 72 – Discharged to another institution
• Some of the descriptions of the discharged status codes were changed prematurely.



Reimbursement Guidelines from UHC insurance

Based on national guidelines for completing and submitting a UB-04 (or the electronic comparative) a provider must assign a Patient Discharge Status code which aligns with the type of bill (TOB) submitted.

United HealthCare Community Plan requires Patient Discharge Status codes for:

** Hospital Inpatient Claims (TOBs 11X and 12X);
** Skilled Nursing Claims (TOBs 18X, 21X, 22X and 23X);
** Outpatient Hospital Claims (TOBs 13X, 14X, 71X, 73X, 74X, 75X, 76X and 85X); and
** All Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X and 82X).

The appropriate type of bill is determined based on the following guidance from the NUBC:
** The first digit is a leading zero.
** The second digit is the type of facility.
** The third digit classifies the type of care being billed.
** The fourth digit indicates the sequence of the bill for a specific episode of care. The fourth digit is commonly referred to as the “frequency” code.

The fourth digit is indicative of the submission frequency, and should align with the Patient Discharge Status reported on the claim. A type of bill with a frequency reflective of an ongoing stay should align with a discharge status indicating that the patient is still receiving care. Additionally, a type of bill reflective of a discharge or final claim should be reported with a Patient Discharge Status that identifies where the patient is at the conclusion of a health care facility encounter, or at the end of a billing cycle (the ‘through' date of a claim).

It is important to select the correct Patient Discharge Status code. In cases in which two or more Patient Discharge Status codes apply, providers should code the highest level of care known. UnitedHealthCare Community Plan will deny claims when the Patient Discharge Status is inconsistent with the type of bill reported.


CPT 99217, 99218, 99219, 99220 - Observation care codes


CPT Code Description

99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])

99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.

99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit.



Initial Observation Care (CPT code range 99218-99220)

• Included in Initial Observation Care:
- Initiation of observation status
- Supervision of the care plan for observation
- Performance of periodic reassessments
• When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician.
• When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.
• To report services provided to patient who is admitted to the hospital after receiving hospital observation care services on the same date, see initial  hospital carenotes in the American Medical Association (AMA) Current Procedural Terminology (CPT) Publication.
• To report hospital admission on a date subsequent to the date of observation status, use appropriate initial hospital care codes (CPT 99221 – 99223)
• Observation status that is initiated in the course of an encounter in another site of service (eg. hospital emergency department, office, nursing facility) all E/M services provided by the supervising physician or other qualified health care professional in conjunction with initiating “observation status” are considered part of the initial observation care when performed on the same date.
- The level of service reported should include the services related to initiating “observation status” provided in the other sites of service as well as in the observation setting
• On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.
• Admitted and discharges from observation or inpatient status on the same date report CPT codes 99234-99236 as appropriate; do NOT report observation discharge in conjunction with a hospital admission.
• These codes may NOT be utilized for post-operative recovery if the procedure is considered part of the surgical “package.”




REIMBURSEMENT GUIDELINES from Oxford insurance

Initial Observation Care

The physician supervising the care of the patient designated as "observation status" is the only physician who can report an initial Observation Care CPT code (99218-99220). It is not necessary that the patient be located in an observation area designated by the hospital, although in order to report the Observation Care codes the physician must:

** Indicate in the patient's medical record that the patient is designated or admitted as observation status;
** Clearly document the reason for the patient to be admitted to observation status; and
** Initiate the observations status, assess, establish and supervise the care plan for observation and perform periodic reassessments.

The CPT codebook states that "When "observation status" is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility) all evaluation and management services provided by the supervising physician or other qualified health care professional in conjunction with initiating "observation status" are considered part of the initial Observation Care when performed on the same date. The Observation Care level of service reported by the supervising physician should include the services related to initiating "observation status" provided in the other sites of services as well as in the observation setting."

Oxford follows the Centers for Medicare and Medicaid Services' (CMS) Claims Processing Manual which provides the instructions, "for a physician to bill the initial Observation Care codes [99218-99220], there must be a medical observation record for the patient which contains dated and timed physician's admitting orders regarding the care the patient is to receive while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter."

Consistent with CMS guidelines, Oxford requires that an Initial Observation Care CPT code (99218-99220) should be reported for a patient admitted to Observation Care for less than 8 hours on the same calendar date.



Q: Can Observation Care codes 99217 and codes 99218-99220 be reported on the same date of service?
A: No. CPT codes 99234-99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours but less than 24. An initial Observation Care code (99218-99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on the same calendar date. CPT code 99217 can only be reported for a patient discharged on a different calendar date.

Q: Does the patient need to be in an observation unit in order to report the Observation Care codes?

A: It is not necessary that the patient be located in an observation area designated by the hospital as long as the medical record indicates that the patient was admitted as observation status and the reason for Observation Care is documented.




Observation Services limitation

Hospital observation (procedure codes 99217, 99218, 99219, and 99220) are professional services  provided for a period of more than 6 hours but fewer than 24 hours regardless of the hour of the initialcontact, even if the client remains under physician care past midnight. Subsequent observation care, per day (procedure codes 99224, 99225, and 99226) is also a benefit of Texas Medicaid. Inpatient hospital observation services must be submitted using the procedure code 99234, 99235, or 99236.

Observation care discharge day management procedure code 99217 must be billed to report services provided to a client upon discharge from observation status if the discharge is on a date other than the initial date of admission. The following procedure codes are denied if submitted with the same date of service as procedure code 99217:

Procedure Codes

99211 99212 99213 99214 99215 99218 99219 99220

If an E/M service is billed by the same provider with the same date of service as a physician observation visit, the E/M service is denied if provided in any place of service other than inpatient hospital. If a physician observation visit (procedure code 99217, 99218, 99219, 99220, 99234, 99235, or 99236) is billed by the same provider with the same date of service as prolonged services (procedure code 99354, 99355, 99356, or 99357), the prolonged services will be denied as part of another procedure on the same day.

If dialysis treatment and a physician observation visit are billed by the same provider (and same specialty other than an internist or nephrologist) with the same date of service, the dialysis treatment may be reimbursed and the physician observation visit will be denied.

CPT H0031 - Mental health assessment program

Procedure Code and Unit of Service:  

H0031 – Mental Health Assessment by a Non-Mental Health Therapist – per 15 minutes


 Mental Health Assessment  Guidelines from Medicaid

Mental Health Assessment means providers listed below, participating as part of a multi-disciplinary team, assisting in the psychiatric diagnostic evaluation process defined in Chapter 2-2, Psychiatric Diagnostic Evaluation.  Through  face-to-face  contacts  with  the  individual,  the  provider  assists  in  the  psychiatric diagnostic  evaluation  process  by  gathering  psychosocial  information  including  information  on  the individual’s  strengths,  weaknesses  and  needs,  and  historical,  social,  functional,  psychiatric,  or  other information and assisting the individual to identify treatment goals. The provider assists in the psychiatric diagnostic  reassessment/treatment  plan  review  process  specified  in  Chapter  2-2  by  gathering  updated psychosocial information and updated information on treatment goals and assisting the client to identify additional treatment goals. Information also may be collected through in-person or telephonic interviews with family/guardians or other sources as necessary. The information obtained is provided to the individual identified in Chapter 2-2 who will perform the assessment, reassessment or treatment plan review.

Who:   


The following individuals when under the supervision of a licensed mental health therapist identified in Chapter 1-5, A. 1:

1.  licensed social service worker or individual working toward licensure as a social service worker in accordance with state law;

2.  licensed registered nurse;

3.  licensed ASUDC, CASUDC, SUDC, CSUDC or ASUDC-I or SUDC-I;  

4.  licensed practical nurse; or
 
5.  registered nursing student engaged in activities constituting the practice of a regulated occupation or profession while in training in a recognized school approved by DOPL, or an individual enrolled in a qualified substance use disorder education program, exempted from licensure in accordance with state law, and under required supervision. 

  Although these individuals may perform this service and participate as part of a multi-disciplinary team, under state law, qualified providers identified in Chapter 2 -2 are the only providers who may diagnose a behavioral health disorder and prescribe behavioral health services determined to be medically necessary to treat the individual’s behavioral health disorder(s). 

   Limits: 

1.  This service is meant to accompany the psychiatric diagnostic evaluation (see Chapter 2-2).  If a psychiatric diagnostic evaluation (assessment or reassessment) is not conducted after this service is performed, this service may be billed if all of the documentation requirements in the ‘Record’ section are met and the reason for non-completion of the psychiatric diagnostic evaluation is documented.

2.  If the provider conducting the psychiatric diagnostic evaluation defined in Chapter 2-2 obtains all of the psychosocial information directly from the client, only that service is billed.  The provider does not also bill this service. 


Time and Unit calculation

The following time rules apply for converting the duration of the service to the specified number of units:

Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.


CPT code H0031
- Maximum fee - $125.00 per assessment
Description of Service - In-depth assessment, new patient, mental health , In-depth assessment, new patient, mental health—telemedicine.
Limitation -  Medicaid reimburses one in-depth assessment, per recipient, per state fiscal year.* An in-depth assessment is not reimbursable on the same day for the same recipient as a bio-psychosocial evaluation. A bio-psychosocial evaluation is not reimbursable for the same recipient after an in-depth assessment has been completed, unless there is a documented change in the recipient’s status and additional information must be gathered to modify the recipient’s treatment plan.

Tips for usage

HSD/Medicaid will use this code for PSR only. Use modifier U8.
** For multi-disciplinary team, use modifier HT.
** For substance abuse assessment, use modifier HF.
** For substance abuse/mental health assessment, use modifier HH

Eligible Provider

** Bachelor’s degree in human servicesrelated field and a combination of relevant education, training, and experience totaling four years; or
** LADAC; or
** Masters Degree in human servicesrelated field.

NOTE: Completed assessment must be signed and dated by staff completing the assessment and, as appropriate, a masters level supervisor.

CPT code 99050, 99051, 99053, 99056 - After Office hour procedures

Procedure code and Description

99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic


Medicaid Guideline for office hour CPT

 After-hours office visit codes cannot be used in a hospital setting, including emergency  department, by private or staff physicians. They cannot be used for standby for surgery, delivery, or other similar circumstances, and they cannot be used when seeing a new patient.  Billing for after-hours service in an established patient requires the service be provided outside  of scheduled staff hours as described in the Medicaid manual.

Policy Name After Hours and Weekend Care

This policy addresses reimbursement of after hours and weekend care services (Current Procedural Terminology (CPT) codes 99050-99060).

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.These codes have a Status Indicator of “B” in the National Physician Fee Schedule (NPFS).  Consistent with CMS, Medica considers these codes not eligible for reimbursement.

Definitions

Same Physician The same individual rendering health care services reporting the same Federal Tax Identification number.

Status Indicator B


Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient).

BCBS payment Guidelines

CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.

CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service;

•It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours; and

•The basic service time is based on arrival time, not actual time services commence.

CPT code 99050 is not eligible for separate reimbursement when it is  reported with a preventive diagnosis and/or a preventive service.CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours.

CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service; and

•The basic service time for evening hours is based on arrival time, not actual time the service commenced. E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement


CPT Code 99050

Although CMS considers CPT code 99050 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes.

Oxford will reimburse after hours CPT code 99050 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:

POS Code  Description

03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71 State or local public health clinic
72 Rural health clinic Oxford will reimburse the following participating primary care providers for CPT 99050:

* Adolescent medicine, pediatric-adolescent, pediatrics
*Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
*Family practice
*General practice
*Geriatric medicine
*Gynecology, obstetrics & gynecology, obstetrics
*Internal medicine
*Certified nurse mid


Questions and Answers

1Q: Why doesn't United Healthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?

A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hour as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

2Q:  When will United Healthcare provide reimbursement for CPT code 99050?A:  United Healthcare will provide reimbursement for CPT code 99050 during times other than regularly scheduled office hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.

3Q:  When will United Healthcare provide reimbursement for CPT code 99051?


A:  United Healthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).

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