OUTPATIENT PARTIAL HOSPITALIZATION SERVICES
The PIHP is responsible for authorizing and paying for Medicaid admissions and continued stays in partial hospitalization programs by Medicaid beneficiaries.
* Admissions – beneficiaries may be referred to a partial hospitalization program from psychiatric inpatient hospitals or psychiatric units, referring providers, or PIHPs, or they may present themselves at the outpatient hospital without a
referral.
* Continued stays must be authorized by the PIHP.
Authorization for the partial hospitalization admission and continued stay includes authorization for all services related to that admission/stay, including laboratory, pharmacy, and radiology services. The outpatient partial hospitalization program must bill the PIHP for authorized services according to procedures and rates established between the facility and the PIHP.
PARTIAL HOSPITALIZATION ADMISSION CRITERIA: ADULT
Partial hospitalization services may be used to treat a person with mental illness who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week, in a licensed setting. The use of partial hospitalization as a setting of care presumes that the beneficiary does not currently need treatment in a 24-hour protective environment. Conversely, the use of partial hospitalization implies that routine outpatient treatment is of insufficient intensity to meet the beneficiary’s present treatment needs. The SI/IS criteria for admission assume that the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating significant functional impairments in self-care, daily living skills,
interpersonal/social and/or educational/vocational domains, and is exhibiting some evidence of clinical instability. However, the level of symptom acuity, extent of functional impairments and/or the estimation of risk (clinical instability) do not justify or necessitate treatment at a more restrictive level of care. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care.
The individual must meet all three criteria outlined in the table below: Diagnosis The beneficiary must be suffering from a mental illness, reflected in a primary,validated, current version of DSM or ICD Diagnosis (not including ICD-9 V-codes and
ICD-10 Z-codes).
Severity of Illness (signs, symptoms, functional impairments and risk potential)
At least two of the following manifestations are present:
* Psychiatric Signs and Symptoms
* Some prominent disturbance of thought processes, perception, affect, memory, consciousness, somatic functioning (due to a mental illness) or behavior exists (intermittent hallucinations, transient delusions, panic reactions, agitation, obsessions/ruminations, severe phobias, depression, etc.) and is serious enough to cause disordered or aberrant conduct, impulse control problems, questionable judgment, psychomotor acceleration or retardation, withdrawal or avoidance, compulsions/rituals, impaired reality testing and/or impairments in functioning and role performance. The
disordered or aberrant conduct or activity and/or the level of agitation are not so severe, extreme or unstable so as to require frequent restraints or to pose a danger to others.
* Disruptions of Self-Care and Independent Functioning
* The person seriously neglects self-care tasks (hygiene, grooming, etc.) and/or does not sufficiently attend to essential aspects of daily living (does not shop, prepare meals, maintain adequate nutrition, pay bills, complete housekeeping chores, etc.) due to a mental disorder.
* Beneficiary is able to maintain adequate nutrition, shelter or other essentials of daily living only with structure and supervision for a significant portion of the day, and with family/community support when away from the partial
hospitalization program.
* The person’s interpersonal functioning is significantly impaired (seriously dysfunctional communication, extreme social withdrawal, etc.).
* There has been notable recent deterioration in meeting educational/occupational responsibilities and role performance expectations.
* Danger to Self
* There is modest danger to self, reflected in: intermittent self-harm ideation, expressed ambivalent inclinations without a plan, non-intentional threats, mild and infrequent self-harm gestures (low lethality/intent) or selfmutilation, passive death wishes, or slightly self-endangering activities.
* The beneficiary has not made any recent significant (by intent or lethality) suicide attempts, nor is there any well-defined plan for such activity or, if there have been recent significant actions, these inclinations/behaviors are
now clearly under control and the pers on no longer needs/requires 24-hour supervision to contain self-harm risk.
* Danger to Others
* Where assaultive tendencies exist, there have been no overt actions and there is reasonable expectation, based upon history and recent behavior, that the beneficiary will be able to curb these inclinations.
* There have been destructive fantasies described and mild threats verbalized, but the beneficiary appears to have impulse control, judgment, and reality orientation sufficient to suppress urges to act on these imaginings or expressions.
* There has been minor destructive behavior toward property without endangerment of others.
Drug/Medication Complications
* The beneficiary has experienced side effects of atypical complexity resulting from psychotropic drugs, and regulation/correction/monitoring of these circumstances cannot be accomplished at a lower level of care due to the beneficiary’s condition or to the nature of the procedures involved.
* The beneficiary needs evaluation and monitoring due to significant changes in medication or because of problems with medication regimen compliance. Intensity of Service The person meets the intensity of service requirements if partial hospitalization services are considered medically necessary and the person requires at least one of the following:
* The person requires intensive, structured, coordinated, multi-modal treatment and supports with active psychiatric supervision to arrest regression and forestall the need for inpatient care.
* The beneficiary has reached a level of clinical stability (diminished risk) obviating the need for continued care in a 24-hour protective environment but continues to require active, intensive treatment and support to relieve/reverse disabling
psychiatric symptomatology and/or residual functional impairments.
* Routine medical observation and supervision is required to effect significant regulation of psychotropic medications and/or to minimize serious side effects.
PARTIAL HOSPITALIZATION ADMISSION CRITERIA: CHILDREN AND ADOLESCENTS
Partial hospitalization services may be used to treat a child or adolescent with mental illness or serious emotional disturbance who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week, in a licensed setting. The use of partial hospitalization as a setting of care presumes that the beneficiary does not currently need treatment in a 24-hour protective environment. Conversely, the use of partial hospitalization implies that routine outpatient treatment is of insufficient intensity to meet the beneficiary’s present treatment needs. The SI/IS criteria for admission assume that
the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating significant functional impairments in self-care, daily living skill, interpersonal/social and/or educational/vocational domains, and is exhibiting some evidence of clinical instability. However, the level of symptom acuity, extent of functional impairments and/or the estimation of risk (clinical instability) does not justify or necessitate treatment at a more restrictive level of care.
Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care.
The individual must meet all three criteria outlined in the following table:
Diagnosis The beneficiary must be suffering from a mental illness, reflected in a primary, validated, current version of DSM or ICD diagnosis (not including ICD-9 V-codes and ICD-10 Z-codes).
* Danger to Others
* Assaultive tendencies exist, and some assaultive behavior may have occurred, but any overt actions have been without any serious or significant injury to others, and there is reasonable expectation, based upon history and recent behavior, that the beneficiary will be able to curb any serious expression of these inclinations.
* There have been destructive fantasies described and mild threats verbalized, but the beneficiary appears to have adequate impulse control, judgment, and reality orientation sufficient to suppress urges to act on these imaginings or expressions.
* There has been minor destructive behavior toward property without endangerment of others.
* Drug/Medication Complications
* The beneficiary has experienced side effects of atypical complexity resulting from psychotropic drugs and regulation/correction/monitoring of these circumstances cannot be accomplished at a lower level of care due to the beneficiary’s condition or to the nature of the procedures involved.
* The beneficiary needs evaluation and monitoring due to significant changes in medication or because of problems with medication regimen compliance.
Intensity of Service The person meets the intensity of service requirements if partial hospitalization services are considered medically necessary and the person requires at least one of the following:
* The person requires intensive, structured, coordinated, multi-modal treatment and supports with active psychiatric supervision to arrest regression and forestall the need for inpatient care.
* The beneficiary has reached a level of clinical stability (diminished risk) obviating the need for continued care in a 24-hour protective environment but continues to require active, intensive, treatment and support to relieve/reverse disabling
psychiatric symptomatology and/or residual functional impairments.
* Routine medical observation and supervision is required to effect significant regulation of psychotropic medications and/or to minimize serious side effects.
10.3 PARTIAL HOSPITALIZATION CONTINUING STAY CRITERIA FOR ADULTS, ADOLESCENTS AND CHILDREN
After a beneficiary has been certified for admission to a partial hospitalization program, services will be reviewed at regular intervals to assess the current status of the treatment process and to determine the continued necessity for care in a partial hospitalization setting. Treatment within a partial hospitalization program is directed at resolution or stabilization of acute symptoms, elimination or amelioration of disabling functional impairments, maintenance of self/other safety and/or regulation of precarious or complicated medication situations. The continuing stay recertification process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the partial
program remains the most appropriate, least restrictive, level of care for treatment of the beneficiary’s problems and dysfunctions.
Continuing treatment in the partial program may be certified when symptoms, impairments, harm inclinations or medication complications, similar to those which justified the beneficiary’s admission certification, remain present, and continue to be of such a nature and severity that partial hospitalization treatment is still medically necessary. It is anticipated that in those reviews which fall near the end of an episode of care, these problems and dysfunctions will have stabilized or diminished. Discharge planning must begin at the onset of treatment in the program. Payment cannot be authorized
for continued stays that are due solely to placement problems or the unavailability of aftercare services. The individual must meet all three criteria outlined in the following table:
Diagnosis The beneficiary has a validated current version of DSM or ICD mental disorder (excluding ICD-9 V-codes and ICD-10 Z-codes), which remains the principal diagnosis for purposes of care during the period under review.
Severity of Illness (signs, symptoms, functional impairments and risk potential)
* Persistence of symptoms, impairments, harm inclinations or medication complications which necessitated admission to this level of care, and which cannot currently be addressed at a lower level of care.
* Emergence of new symptoms, impairments, harm inclinations or medication complications meeting admission criteria.
* Progress has been made in ameliorating admission symptoms or impairments, but the treatment goals have not yet been fully achieved and cannot currently be addressed at a lower level of care.
Intensity of Service * The beneficiary is receiving active, timely, intensive, structured multi-modal treatment delivered according to an individualized plan of care.
* Active treatment is directed toward stabilizing or diminishing those symptoms, impairments, harm inclinations or medication complications that necessitated admission to the program.
* The beneficiary is making progress toward treatment goals or, if no progress has been made, the treatment plan and therapeutic program have been revisedaccordingly and there is a reasonable expectation of a positive response to treatment.
Discharge criteria and aftercare planning are documented in the beneficiary’s record.
PERSONAL CARE IN LICENSED SPECIALIZED RESIDENTIAL SETTINGS
Personal care services are those services provided in accordance with an individual plan of service to assist a beneficiary in performing his own personal daily activities. Services may be provided only in a licensed foster care setting with a specialized residential program certified by the state. These personal care services are distinctly different from the state plan Home Help program administered by MDHHS. Personal care services are covered when authorized by a physician or other health care professional in accordance with an individual plan of services, and rendered by a qualified person. Supervision of personal care services must be provided by a health care professional who meets the qualifications contained in this chapter.
- Those patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment.
- Those patients who, in the absence of partial hospitalization, would require inpatient hospitalization.
- Medically necessary diagnostic services related to mental illness.
- 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 worker).
- Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physician’s treatment plan for the individual. While occupational therapy may include prevocational and vocational assessment and training, when the services are related primarily to specific employment opportunities, work skills or work settings, they are not covered.
- Services of other staff trained to work with psychiatric patients (individual, family and group psychotherapy) must be performed by individuals authorized or licensed by the state in which they practice to provide these services.
- Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes. For example, oral medications that can be self-administered are not covered. (Note: Medication must be safe and effective, and approved by the Food and Drug Administration. It cannot be experimental or administered under an investigational protocol.)
- 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. The physician’s treatment plan must clearly justify the need for each particular activity therapy modality utilized, and explain how it fits into the treatment of the patient’s illness and functional deficits. Providers should not bill activity therapies as individual or group psychotherapy services. These services must be performed by individuals licensed to provide these services.
- Family counseling services for which the primary purpose is the treatment of the patient’s condition. Such services include the need to observe the patient’s interaction with the family for diagnostic purposes, or to assess the capability of and assist the family members in aiding in the management of the patient. Counseling the family to aid in the management of the patient may include attempts to modify the behavior of the family members.
- Patient education programs, but only where the educational activities are closely related to the care and treatment of the patient.
- Diagnostic services for the purpose of diagnosing those individuals for whom an extended or direct observation is necessary to determine functioning and interactions, identify problem areas and formulate a treatment plan.
- Day care programs, which provide primarily social, recreational, or diversional activities, custodial or respite care.
- Programs attempting to maintain psychiatric wellness, e.g., daycare programs for the chronically mentally ill.
- Treatment of chronic conditions without acute exacerbation.
- Services to a nursing facility resident that should be expected to be provided by the nursing facility staff.
- Vocational training.
- Patients who refuse or cannot participate (due to their behavioral, cognitive or emotional status) with active treatment of their mental disorder, or who cannot tolerate the intensity of a PHP.
- Patients who require 24-hour supervision because of the severity of their mental disorder or their safety or security risk (i.e. homicidal or suicidal).
- Patients who require primarily social, custodial, recreational or respite care.
- Patients with multiple absences or who are persistently non-compliant.
- Patients who do not participate in active treatment for at least four days per week with a minimum of 20 hours per week.
- Patients who have met the criteria for discharge from the PHP, or who require inpatient hospitalization.
- Services to hospital inpatients.
- Meals, self-administered medications and transportation.
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Note:
|
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
|
90801©
|
Psy dx interview
|
90802©
|
Intac psy dx interview
|
90816©
|
Psytx, hosp, 20 to 30 min
|
90817©
|
Psytx, hosp, 20 to 30 min with medical evaluation and management services
|
90818©
|
Psytx, hosp, 45 to 50 min
|
90819©
|
Psytx, hosp, 45 to 50 min with medical evaluation and management services
|
90821©
|
Psytx, hosp, 75 to 80 min
|
90822©
|
Psytx, hosp, 75 to 80 min with medical evaluation and management services
|
90823©
|
Intac psytx, hosp, 20 to 30 min
|
90824©
|
Intac psytx, hosp, 20 to 30 min with medical evaluation and management services
|
90826©
|
Intac psytx, hosp, 45 to 50 min
|
90827©
|
Intac psytx, hosp, 45 to 50 min with medical evaluation and management services
|
90828©
|
Intac psytx, hosp, 75 to 80 min
|
90829©
|
Intac psytx, hosp, 75 to 80 min with medical evaluation and management services
|
90846©
|
Family psytx w/o patient
|
90847©
|
Family psytx w/patient
|
90849©
|
Multiple family group psytx
|
90853©
|
Group psychotherapy
|
90857©
|
Intac group psytx
|
90899©
|
Psychiatric service/therapy
|
96101©
|
Psycho testing by psych/phys
|
96102©
|
Psycho testing by technician
|
96103©
|
Psycho testing admin by comp
|
96105©
|
Assessment of aphasia
|
96110©
|
Developmental test, lim
|
96111©
|
Developmental test, extend
|
96116©
|
Neurobehavioral status exam
|
|
Note: Must be accomplished by psychologist or physician (see CPT code long description).
|
96118©
|
Neuropsych tst by psych/phys
|
96119©
|
Neuropsych testing by tech
|
96120©
|
Neuropsych tst admin w/comp
|
96125©
|
Cognitive test by hc pro
|
97003©
|
OT evaluation
|
97004©
|
OT re-evaluation
|
97530©
|
Therapeutic activities
|
97532©
|
Cognitive skills development
|
97533©
|
Sensory integration
|
97535©
|
Self care mngment training
|
97537©
|
Community/work reintegration
|
G0129
|
Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day
|
G0176
|
Activity therapy furnished in connection with partial hospitalization (e.g., music, dance, art or play therapies that are not primarily recreational), per visit
|
G0177
|
Training and educational services furnished as a component of a partial hospitalization program, per day
|
G0410
|
Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes
|
G0411
|
Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes
|
291.3
|
Alcohol-induced psychotic disorder with hallucinations
|
291.82
|
Alcohol-induced sleep disorders
|
291.89
|
Other specified alcohol-induced mental disorders
|
292.11–292.12
|
Drug-induced psychotic disorders
|
292.84–292.85
|
Other specified drug-induced mental disorders
|
292.89
|
Other specified drug-induced mental disorders
|
293.81–293.84
|
Other specified transient mental disorders due to conditions classified elsewhere
|
295.10
|
Schizophrenia, disorganized type, unspecified
|
295.20
|
Catatonic type, unspecified
|
295.30
|
Paranoid type, unspecified
|
295.40
|
Schizophreniform disorder, unspecified
|
295.70
|
Schizoaffective disorder, unspecified
|
295.90
|
Schizophrenia, undifferentiated type, unspecified
|
296.01–296.05
|
Bipolar I disorder, single manic episode
|
296.11–296.15
|
Manic disorder, recurrent episode
|
296.21–296.25
|
Major depressive disorder, single episode
|
296.31–296.35
|
Major depressive disorder, recurrent episode
|
296.41–296.45
|
Bipolar I disorder, most recent episode (or current) manic
|
296.51–296.55
|
Bipolar I disorder, most recent episode (or current) depressed
|
296.61–296.65
|
Bipolar I disorder, most recent episode (or current) mixed
|
296.7
|
Bipolar I disorder, most recent episode (or current) unspecified
|
296.80–296.82
|
Other and unspecified bipolar disorders
|
296.89
|
Other and unspecified bipolar disorders, other
|
297.1
|
Delusional disorder
|
297.3
|
Shared psychotic disorder
|
298.8–298.9
|
Other non-organic psychoses
|
303.91–303.92
|
Other and unspecified alcohol dependence
|
304.01–304.02
|
Opioid type dependence
|
304.11–304.12
|
Sedative, hypnotic or anxiolytic dependence
|
304.21–304.22
|
Cocaine dependence
|
304.41–304.42
|
Amphetamine and other psycho stimulant dependence
|
304.61–304.62
|
Inhalant dependence
|
304.71–304.72
|
Combination of opioid type drug with any other
|
307.1
|
Anorexia nervosa
|
307.51
|
Bulimia nervosa
|
308.3
|
Other acute reaction to stress
|
311
|
Depressive disorder, NEC
|
327.02
|
Insomnia due to mental disorder
|
327.15
|
Hypersomnia due to mental disorder
|
327.42–327.43
|
Organic parasomnia
|
780.93
|
Memory loss
|
- Description of acute illness or exacerbation of chronic illness requiring admission.
- Current medical history, including medications and evidence of failure at or inability to benefit from a less-intensive outpatient program.
- Past psychiatric and medical history.
- History of substance abuse.
- Family, vocational and social history, including documentation of an adequate support system to sustain/maintain the patient outside the PHP.
- Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long- and short-term memory, estimate of intelligence, capacity for self-harm and harm to others, insight, judgment and capacity for Activities of Daily Living (ADLs).
- Physical examination (if not done within the past 30 days and available for inclusion in the medical record).
- Formulation of the patient’s status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the PHP.
- ICD-9-CM or DSM-IV diagnoses, including all five axes of the multiaxial assessment as described in the DSM-IV.
- Treatment plan, including long- and short-term goals related to the active treatment of the reason for admission and types, amount, duration and frequency of therapy services, including activity therapy, required to address the goals.
- The patient’s response to therapeutic interventions provided by the PHP.
- The patient’s psychiatric symptoms that continue to place the patient at risk of hospitalization.
- Treatment goals for coordination of services to facilitate discharge from the PHP.
CPT Code
|
Code Description
|
Timed/
Untimed
|
Allowed Units
|
Physician/NPP Not Under a Therapy POC
|
||
PT
|
OT
|
SLP
|
||||
96110
|
Developmental test, lim
|
Untimed
|
1
|
1
|
1
|
1
|
96111
|
Developmental test, extend
|
Untimed
|
1
|
1
|
1
|
1
|
97003
|
OT evaluation
|
Untimed
|
0
|
1
|
0
|
N/A
|
97004
|
OT re-evaluation
|
Untimed
|
0
|
1
|
0
|
N/A
|