Partial Hospitalization Programs (PHPs) – Psychiatric CPT code List 90801 - 97537


The concept of Partial Hospitalization Programs (PHP) is to maintain the patient with a chronic behavioral disorder in a controlled environment, providing psychotherapeutic and pharmacologic support as indicated on a daily basis, without requiring an inpatient hospitalization. Patients admitted to a PHP must be under the care of a physician who is knowledgeable about the patient and certifies the need for partial hospitalization. The patient or legal guardian must provide written informed consent for partial hospitalization treatment. The patient must require comprehensive, multimodal treatment requiring medical supervision and coordination because of a mental disorder that severely interferes with multiple areas of daily life, including social, vocational and/or educational functioning. Such dysfunction must be of an acute nature and not a chronic circumstance.
Patients eligible 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.
  • Those patients who, in the absence of partial hospitalization, would require inpatient hospitalization.
There must be a reasonable expectation of improvement in the patients disorder and level of functioning as a result of the active treatment provided by the PHP. True partial hospitalization providing comprehensive behavioral benefits will optimally utilize the same services as inpatient psychiatric care, although possibly with less intensity. Active treatment directly addresses the presenting problems requiring admission to the PHP. Active treatment consists of clinically recognized therapeutic interventions including individual, group, and family psychotherapies and occupational, activity and psycho-educational groups pertinent to the patients illness. Medical and psychiatric diagnostic evaluation and medication management are also integral to active treatment. The patient must have the capacity for active participation in all phases of the multidisciplinary and multimodal program. If a substance abuse disorder is also present, the program must be prepared to appropriately treat the comorbid substance abuse disorder (dual diagnosis patients). A program composed primarily of activity, social or recreational therapy does not constitute a PHP. Psychosocial programs that provide only a structured environment, socialization and/or vocational rehabilitation are not covered by Medicare.
Admission Criteria
In general, patients should be treated in the least intensive and restrictive setting that meets the needs of their illness. Patients admitted to a PHP do not require a 24-hour per day level of care as provided in an inpatient setting, and must have an adequate support system to sustain/maintain themselves outside the PHP. At the same time, a PHP level of care must be necessary to prevent inpatient hospitalization, and there must be evidence of failure at, or inability to benefit from, a less intensive outpatient program.
The acute psychiatric condition being treated by a PHP must require active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require PHP services at levels of intensity and frequency comparable to patients in an inpatient setting for similar psychiatric illnesses.
Patients admitted to a PHP must have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) published by the American Psychiatric Association (1994) (see covered ICD-9-CM codes), which severely interferes with multiple areas of daily life. Patients admitted to a PHP will usually have a level of functioning below 40, as measured using the Global Assessment of Functioning Scale found in the DSM-IV. The degree of impairment will be severe enough to require a multidisciplinary structured program, but not so severe that patients are incapable of participating in and benefiting from an active treatment program, and able to be maintained outside the program. For patients who do not meet this degree of severity of illness, and for whom partial hospitalization services are not necessary, professional services of psychiatrists and psychologists may be medically necessary, even though partial hospitalization services are not.
Patients admitted for treatment to a PHP will not be in immediate/imminent danger to self, others or property, but there may be a recent history of self-mutilation, serious risk-taking or other self-endangering behavior.
PHPs must have program availability of 20 hours or more per week. Patients entering a PHP require participation of at least four days per week with a minimum of 20 hours per week of active treatment, as evidenced by the plan of care, which would be reasonable and necessary for patients to participate in a PHP.
Discharge Criteria
Patients in PHPs may be discharged by either stepping up to an inpatient level of care or stepping down to a less-intensive level of outpatient care. Inpatient admission would be required for patients needing 24-hour supervision because of probability for self-harm, harm to others or inability to care for self outside the hospital. Stepping down to a less-intensive level of service than partial hospitalization would be considered when patients no longer require a multidisciplinary and multimodal program as described above. These patients would become outpatients and individual mental health services could then be billed by appropriate providers.
Patients whose clinical condition improves or stabilizes, and who cannot benefit from or do not still require the intensive, multimodal treatment available in a PHP, should be stepped down to outpatient care. Patients whose global assessment of functioning is above 40 would usually be appropriate for discharge to a less-intensive level of care. Patients unwilling or unable to participate in a PHP would also be appropriate for discharge.
Covered Services
The following may be covered partial hospitalization services:
  • 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.
Non-Covered Services
The following services do not represent reasonable and necessary partial hospitalization services and coverage is excluded under Section 1862(a)(1)(A) of the Social Security Act:
  • 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.
It is not reasonable and necessary to provide partial hospitalization services to the following types of patients and coverage is excluded under Section 1862(a)(1)(A) of the Social Security Act:
  • 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.
The following services are excluded from the scope of partial hospitalization services defined in Section 1861(ff) of the Social Security Act:
  • Services to hospital inpatients.
  • Meals, self-administered medications and transportation.
Allowed unit limitations (once per provider, per discipline, per date of service, per patient) by discipline for CPT codes 96110, 96111, 97003 and 97004 are described in the “Utilization Guidelines” section below.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • 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.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
13X, 76X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
0250, 042X, 043X, 044X, 0900, 0904, 0914, 0915, 0916, 0918, 0942
CPT/HCPCS Codes
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
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Note: Medicare is not establishing limited coverage for CPT codes 97003, 97004, 97532 and 97533 at this time.
Note: For limited coverage of physical therapy and occupational therapy, CPT codes 97530, 97535 and 97537 refer to the Outpatient Physical Medicine and Rehabilitation (4Y-22AB) LCD.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 90801, 90802, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90846, 90847, 90849, 90853, 90857, 90899, 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120, 96125, G0129, G0176, G0177, G0410 and G0411.
Covered for:
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
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
The total number of timed minutes must be documented in the patient’s medical record.
Upon admission, a certification by the physician (MD/DO) must be made that the patient admitted to the partial hospitalization program would require inpatient psychiatric hospitalization if the partial hospitalization services were not provided and must include an attestation that the services are furnished while the individual is under the care of a physician, and that the services are furnished under an individualized written plan of care.
The initial psychiatric evaluation with medical history and physical examination must be performed and placed in the chart within 24 hours of admission in order to establish medical necessity for partial hospitalization services. If the patient is being discharged from an inpatient psychiatric admission to a PHP, the psychiatric evaluation, medical history and physical examination from that admission with appropriate update is acceptable.
To support the medical necessity of admission to the PHP, the documentation in the initial psychiatric evaluationshould include the following items:
  • 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 patients 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.
A team approach may be used in developing the initial psychiatric evaluation, but the physician (MD/DO) must document the mental status examination, physical examination, formulation, diagnosis, treatment plan and certification.
Physician Recertification Requirements: The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient’s response to treatment.
Timing – The first recertification is required as of the 18th calendar day following admission to the PHP. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days.
Content – The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the PHP and describe the following:
  • 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.
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. The treatment plan is established by the physician and should be reviewed at least every 30 days in consultation with appropriate staff members. The treatment plan should be reviewed more frequently if the severity of the clinical condition or changes in the clinical condition of the patient (e.g., change of medication) make it reasonable to do so. The long- and short-term treatment goals described in the treatment plan are the basis for evaluating the patients response to treatment. Treatment goals should be designed to measure the response to treatment, as this relationship will be used in determining whether services are medically necessary. The treatment goals should be measurable, functional, time-framed, and directly related to the reason for admission.
Section 1833(e) of the Social Security Act requires services to be documented for payment to be made. Therefore, aseparate progress note is required for each service billed. The progress note should be written by the team member rendering the service and should include a description of the nature of the treatment service, the patients status (behavior, verbalizations, mental status) during the course of the service, the patients response to the therapeutic intervention and its relation to the long- or short-term goals in the treatment plan. Each progress note should be legible, dated and signed, including the credentials of the rendering provider.
The provider must have available for review upon request a log of partial hospitalization services demonstrating the beneficiary’s treatments, observation and progress, utilizing the CPT codes documented in this policy, and also including the appropriate diagnostic codes from the DSM axis.
Sites of Service
Partial hospitalization services may be covered under Medicare when they are provided in a hospital outpatient department or a Medicare-certified CMHC. Partial hospitalization services rendered within a hospital outpatient department are considered incident to a physicians (MD/DO) services and require physician supervision. The physician supervision requirement is presumed met when services are performed on hospital premises (i.e., certified as part of the hospital). Partial hospitalization services provided in a CMHC require general supervision by a physician (MD/DO). This means that a physician must be at least available by telephone, but is not required to be on the premises of the CMHC at all times. CMHCs must meet applicable certification or licensure requirements of the state in which they operate, and additionally be certified by Medicare. A CMHC is a Medicare provider of services only with respect to the furnishing of partial hospitalization services.
If a hospital outpatient department operates a PHP offsite, the services must be rendered under the direct personal supervision of a physician (MD/DO). If a CMHC operates a PHP offsite, the services are unlikely to be considered medically necessary if not rendered under the direct personal supervision of a physician (MD/DO). Direct personal supervision means that the physician must be physically present in the same office suite and immediately available to provide assistance and direction throughout the time the employee is performing services. Availability on another floor or somewhere else in the institution does not meet this requirement.
Appendices
N/A
Utilization Guidelines
Allowed units outlined in the table below may be billed no more than once per provider, per discipline, per date of service, per patient. The codes allowed zero (0) units in the column for “Allowed Units” may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP) (see CMS CR 5253 for additional detail).
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
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

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