Finger Modifier Guidelines and usage examples




A. Policy

Aetna Better Health of Louisiana implements comprehensive and robust policies to ensure alignment with Louisiana Department of Health (LDH) and to warrant that regulatory standards are met. According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic specific modifiers, such as fingers, toes and coronary artery designate the area or part of the body on which the procedure is performed. It is correct coding to append modifiers to the greatest specificity at all times.

B. Overview

CPT and HCPCS Level II guidelines support the use of anatomic specific modifiers to develop policies which validate the area or part of the body on which a procedure is performed.

Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

C. Definitions

Modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims.

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.

D. Reimbursement Guidelines

When submitting claims, always append an anatomical modifier, when applicable. Louisiana Department of Health Medicaid policy for both the commercial and Medicaid Advantage lines of business is that a claim is incomplete without an anatomical modifier, when applicable

E. Codes/Condition of Coverage

These codes are not all inclusive and for more please refer AMA CPT Manual, the HCPCS Level II Manual. These modifiers can be used with diagnostic, as well as therapeutic services.

Anatomical Modifiers:

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.




LT, RT Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).

Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon. LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)

If the code description is for a structure that occurs multiple times on one side ofthe body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for  73030-LT), then LT and RT are not valid modifiers. (Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for nonpaired procedure codes.)



** To report an unplanned, unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.
** To explain surgery/procedure.

Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction). Example
** January 22 – Patient is seen for an injury to the right index finger. The patient’s finger is amputated at the DIP joint.
** 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure.
** March 15 – Same patient has an amputation of the right leg at femur.
** 27590 – 79 Amputation, thigh, through femur, any level.


Blue Cross Requires use of Anatomical Modifiers

Effective February 1, 2019, Blue Cross and Blue Shield of Minnesota (Blue Cross) will change the Reimbursement Policy titled “General Coding-Modifier Policy”. Submission of anatomical modifiers to specify locations will be required when submitting claims.

Anatomical Modifiers

The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment, effective February 1, 2019 Blue Cross requires the anatomical modifier(s) be submitted in the first modifier position, if applicable.

E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit





Modifier Guidelines

procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.

• Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.

• Modifier AX – item furnished in conjunction with dialysis services. J0604 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease.

They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier.

• HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate sitespecific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”).
• Modifier GQ designates services performed via asynchronous telecommunications system and will not be allowed.
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”
• Modifier MS - six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to Corporate Reimbursement Policy titled “Nonpayment for Serious Adverse Events”
• Modifier RA – Replacement of a DME item
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”)
• Modifier RB – Replacement of a part of DME furnished as part of a repair


7 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18.

CPT code 12001,12018 - Laceration repair


CPT Codes for Laceration Repair 

Laceration 

Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less - cpt 12001



Simple Repairs

CPT Codes 12001 – 12018

** Usually included in all minor and major Usually included in all minor and major surgical procedures

** Cannot be reported separately when performed in conjunction with minor/major procedure

** However, can be reported if that is the only service provided e.g. simple closure of laceration


Intermediate Repairs (12001 – 12057)

Use for repair of wounds or defects which:



**  Require layered closure, one/more deeper layers SC tissue & superficial (nonmuscle) fascia

**  Need prolonged support y g (sum of lengths)

Need obliteration of “dead” space

Need prolonged support



Guidelines:

**  Code by site and length

**  Report in addition to excision code

Note: Not appropriate to be

**  used with excision of benign to control tension

**  used with excision of benign lesions 0.5 cm or less (11400, 11420, 11440) for Medicare & Aetna




Surgical Team

Under some circumstances highly complex procedures are carried out under the “surgical team” concept. Each participating physician would report the basic procedure with the addition of modifier -66.

Starred Surgical (*) Procedures

Certain services listed in the schedule are marked with a star (*) after the CPT® code.

These are relatively small surgical procedures for which the usual global package does not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital block, or topical application.

When the starred (*) service is performed at the time of the initial visit, and theservice is the major service rendered during the visit, an office visit will be paid when billed with CPT® code 99025. Example: procedure code 12001 (repair of laceration) and procedure code 99025 (initial new patient exam) would both be paid.

When the starred (*) service is performed at the time of an initial or other visit involving significant identifiable service(s), the appropriate E/M service is listed in addition to the starred (*) service. Example: when an initial consult is performed and a joint injection is also performed, it is appropriate to bill and be paid for both the consult and the injection.

When a starred (*) service is performed at the time of a follow-up visit and the surgical procedure constitutes the major service, the evaluation and management service is not paid in addition to the surgical procedure. When the starred (*) service requires hospitalization, an appropriate hospital visit is listed, in addition to the starred (*) surgical procedure and its follow-up care.

Note: When follow-up days are listed as "0" the follow-up services shall be billed as independent procedures.

Note: When billing starred (*) surgical procedures for injection codes into bursa, joints, etc., the Injectable medications may be billed separately using 99070 or the appropriate J code listed in Medicare’s Level II codes. The drug shall be reimbursed at AWP.



HELPFUL CODING HINTS

As part of Oxford’s ongoing effort to provide the best service possible to all providers, Oxford periodically reviews claims data to identify issues that can delay processing. This article is the second in a series of updates that will be featured in this publication on a regular basis. One of the areas frequently noted to cause difficulty is the inappropriate use of repair CPT codes in the ranges of 12001 through 13160 (Repair; simple, intermediate, complex). These codes cannot be billed for more than a quantity of one per each group of anatomic site and classification, and are frequently billed incorrectly with multiple quantities (e.g., 12001 quantity 2.) To ensure timely and correct reimbursement, physicians, when repairing multiple wounds, should total the sums of the lengths of the repairs performed in each anatomic site and bill with the appropriate corresponding repair code.

According to the AMA CPT 2001 description, “when multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.” The following example illustrates this rule: The physician performs a simple repair 1 cm in length on the trunk and a simple repair 1.5 cm in length on the arm. The provider should bill CPT code 12001 with a quantity of one, since the total length of the repairs is equal to 2.5 cm. The AMA CPT 2001 description for code 12001 is “simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less.”

Providers should not add lengths of repairs from different groupings of anatomic sites (e.g., ears and legs) and should not add together lengths of different classifications (e.g., simple and complex repairs). Please remember to add the total lengths of repairs for each group of anatomic sites. The codes within the same classification and anatomic site cannot be billed in multiple quantities.




HCPC Code 12001


To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the data provided by CMS:


Step 1. Access the Medicare Physician Fee Schedule Look-up on the CMS website at www.cms.hhs.gov.

Step 2. To find the RVU for the procedure: Provide your search criteria selecting the year, “Single HCPCS Code” and “Relative

Value Units.” To find the GPCI: Provide your search criteria selecting the year, “Single HCPCS Code” and “Geographic Practice Cost Index (GPCI).”

Step 3. To find the RVU for the procedure: On the next page, select “Default Fields.” To find the GPCI: On the next page, select “Specific Locality” and “Default Fields.”

Step 4.

To find the RVU for the procedure:

Continue the process by providing the HCPCS (for this example we are using 12001  Repair superficial wounds in a non-facility setting), and select the appropriate modifier if applicable.

To find the GPCIs for the procedure: Continue the process by selecting the “Carrier Locality” (for this example we are selecting “Rest of Texas”).

Step 5.

To find the RVU for the procedure: Submit your search criteria to find the RVUs for the procedure.

To find the GPCIs for the procedure: Submit your search criteria to find the GPCIs for the locality.

 Step 6. Proceed with the calculations. [(Work RVU x Work GPCI)

+ (PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)]
x Division Conversion Factor
= Division MAR


The MAR for CPT code 12001 (Repair superficial wounds) in a non-facility setting provided for the “Rest of Texas” in 2009 is $184.66.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a facility setting, follow the steps above using the Facility RVUs in place of the Non-facility RVUs.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the Trailblazer website:

Step 1. Go to the TrailBlazer Health Enterprises, LLC website at www.TrailBlazerhealth.com.

Step 2. If you have already registered on this site, sign in. If you have not, you must register to use the site. There is no cost to use this website.

Step 3. Use the Search function on the Homepage to search for ‘Fee Schedules’ and locate the Medicare Fee Schedule.

Step 4. Select the year of the fee schedule you want (2009), your state (Texas), and yourlocality (Rest of Texas) in the appropriate windows.

Step 5. Enter the procedure code (CPT) (and modifier if applicable) about which you seek information.

Step 6. Find the Medicare CF and divide it into the Division CF (2009 CF – $53.68) to derive the Division multiplier.

Step 7. Find the non-facility Participating Amount and multiply the amount by the Division ratio.




CPT U0001,U0002, 87635 - Coronavirus - ICD J12.89, A41.89, B34.2

CPT code and Description

U0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.

U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.

87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.  Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.

There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities to bill Medicare as well as by other health insurers that choose to adopt this new code for such tests. HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets). The Medicare claims processing system will be able to accept these codes on April 1, 2020 for dates of service on or after February 4, 2020.


CPT code and reimbursement rate


U0001 - $35.92

U0002 - $51.33

Modifiers:

The appropriate modifier should be assigned based on the below information,

GT - Via Interactive Audio and Video Telecommunications systems
GQ - Via Asynchronous Telecommunications systems.
95 - Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)
G0 -Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

POS:
​​Telemedicine service can be billed under POS 02.

Diagnosis:
The codes for classifying coronavirus (not associated with SARS) include,
Pneumonia due to coronavirus:  J12.89 (Other viral pneumonia) and B97.29 (Other coronavirus as the cause of diseases classified elsewhere)
Sepsis due to coronavirus:  A41.89 (Other specified sepsis) and B97.29
Other infection caused by coronavirus:  B34.2 (Coronavirus infection, unspecified)
If the provider documents “suspected”, “possible” or “probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828).


Medicaid will start to cover these services effective from March 16th, 2020 and the date of service would be February 4th, 2020.


FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19)

Q1. Do the Essential Health Benefits (EHB) currently include coverage for the diagnosis and treatment of COVID-19?

A1. Yes. EHB generally includes coverage for the diagnosis and treatment of COVID-19.
However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. Nongrandfathered health insurance plans purchased by individuals and small employers, including qualified health plans purchased on the Exchanges, must provide coverage for ten categories of EHB.1 These ten categories of benefits include, among other things, hospitalization and laboratory services. Under current regulation, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the ten EHB categories.

This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID19.2 Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19 related services, including testing and treatment, without cost-sharing, while several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.

Q2. Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?

A2. All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHB. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or may apply other limitations. Quarantine outside of a hospital setting, such as a home, is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to cost-sharing or other limitations.

Q3. When a COVID-19 vaccine is available, will it be covered as EHB, and will issuers be permitted to require cost-sharing?


A3. A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHB without cost-sharing, and before meeting any applicable deductible, when the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.

In addition, as part of a plan’s responsibility to cover prescription drugs as EHB, as described above to cover ACIP-recommended vaccines, if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan’s formulary enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c)

Does Aetna cover the cost of COVID-19 testing for members?

CVS Health recently announced Aetna will waive co-pays and apply no cost-sharing for all diagnostic testing related to COVID-19 and there will be no member out of pocket cost. This policy will cover the cost of physician-ordered testing for patients who meet CDC guidelines, which can be done in any approved laboratory location. Aetna will waive the member costs associated with diagnostic testing at any authorized location for all Commercial, Medicare and Medicaid lines of business. Self-insured plan sponsors will be able to opt-out of this program at their discretion.

How will doctors and hospitals have access to COVID-19 lab testing?

 
Patients who have concerns that they may have been exposed to COVID-19 or may have symptoms of COVID-19 should contact their physician or local/state Department of Health for testing. The test specimens will be obtained and then sent to a laboratory. We are not currently able to do specimen collection or testing at MinuteClinic or CVS Retail pharmacies. The CDC states that coronavirus testing may be performed on patients with a doctor’s approval.

CPT G0104, G0105, G0106, G0120 - Colorectal cancer screening

Procedure code and Description

• CPT 82270 (HCPCS G0107) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneousdeterminations;

• HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy;

• HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;

• HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;

• HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.

Medicare Billing Guidelines


G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.

HCPCS G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0105, Screening Colonoscopy Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (HCPCS G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (HCPCS G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (HCPCS G0120) as an alternative to a screening colonoscopy (HCPCS G0105) in January 2000.

Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (HCPCS G0120) in January 2002.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening colonoscopy, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast bariumenema examination.

Screening Barium Enema Examinations (codes G0106 and G0120).--Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies (see §4180.2 B and C) above apply.

In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema in January 2002.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2000.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.


Code G0106 (colorectal cancer screening; barium enema as an alternative to a screening flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280). Code G0120 (colorectal cancer screening; barium enema as an alternative to a screening colonoscopy; high risk individuals) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).

COLORECTAL CANCER SCREENING TESTS OVERVIEW

The following services are considered colorectal cancer screening services:

• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years,
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years;
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk*;
• CologuardTM - Multitarget Stool DNA (sDNA) Test (effective October 9, 2014)

*Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, C rohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.


Remittance Advice Notices.Denial codes

A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is under 50 years of age, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 6 “the procedure code is inconsistent with the patient’s age,” at the line level along with line level remark code M82 “Service is not covered when beneficiary is under age 50.”

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the time period between the test/procedure has not passed, use existing ANSI X12-835 claim adjustment reason code 119 “Benefit maximum for this time period has been reached” at the line level.

C. If the claim is being denied for a screening colonoscopy (code G0105) or a screening barium enema (G0120) because the beneficiary is not at a high risk, use existing ANSI X12-835 claim adjustment reason code 46 “This procedure is not covered” at the line level along with line level remark code M83 “Service is not covered unless the beneficiary is classified as a high risk.”

D. If the service is being denied because payment has already been made for a similar procedure within the set time frame, use existing ANSI X12-835 claim adjustment reason code 18, “Duplicate claim/service” at the line level along with line level remark code M86 “This service is denied because payment has already been made for a similar procedure within a set timeframe.”

E. If the claim is being denied for a noncovered screening procedure such as G0122, use existing ANSI X12-835 claim adjustment reason code 49, “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.” 4180.10 Ambulatory Surgical Center Facility Fee.--CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center (ASC) facility fee under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998. Code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was added to the ASC list effective for services furnished on or after July 1, 2001. Codes G0105 and G0121 are assigned to ASC payment group 2. The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.3

Covered ICD codes

Routine screening examinations:
V76.41 SCREENING FOR MALIGNANT NEOPLASMS OF THE RECTUM
V76.51 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON
Screening examinations for persons at high risk: (HCPCS Codes G0105 and G0120)
Personal or family history of gastrointestinal neoplasia:
211.3 BENIGN NEOPLASM OF COLON
211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL
235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND
RECTUM
V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN
GASTROINTESTINAL TRACT
V10.05* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE
V10.06* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER
V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES
V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL
TRACT
V18.51 FAMILY HISTORY, COLONIC POLYPS
555.1* REGIONAL ENTERITIS OF LARGE INTESTINE
555.2* REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE
555.9* REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0* ULCERATIVE (CHRONIC) ENTEROCOLITIS
556.1* ULCERATIVE (CHRONIC) ILEOCOLITIS
556.2* ULCERATIVE (CHRONIC) PROCTITIS
556.3* ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS
556.4 PSEUDOPOLYPOSIS OF COLON
556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS
556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
556.8* OTHER ULCERATIVE COLITIS
556.9* ULCERATIVE COLITIS UNSPECIFIED



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.




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