Partial Hospitalization Program Interim Billing Guidelines

Partial Hospitalization Program Interim Billing Guidelines March 2013 1449_0313

Today s Presenters Christine Janiszcak, Provider Outreach & Education Consultant Pat Zachmann, Provider Outreach & Education Consultant 2 National Government Services, Inc.

Today's PowerPoint Presentation PowerPoint available on events calendar Go to the http://www.ngsmedicare.com Web site Select Medicare Part A Home Page Click on the Training Events Calendar underneath Education and Training section Select the J13: Partial Hospitalization Program Interim Billing Guidelines Under attachments you will see the PowerPoint presentation link 3 National Government Services, Inc.

Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov. 4 National Government Services, Inc.

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Acronyms APC Ambulatory Payment Classification CAH Critical Access Hospital CC Condition code CMHC Community Mental Health Center CMS Centers for Medicare & Medicaid Services CNS Clinical Nurse Specialist CPT Current Procedural Terminology CR Change request CSW Clinical Social Worker CY Cost year DOS Date of service FISS Fiscal Intermediary Standard System 6 National Government Services, Inc.

Acronyms FL Form locator HCPCS Healthcare Procedure Coding System HIPPS Health Insurance Prospective Payment System HOPD Hospital Outpatient Department IOM Internet-only manual LCD Local coverage determination LIDOS Line item date of service LOA Leave of absence LOC Level of care MAC Medicare Administrative Contractor MUC Medicare University Credit NP Nurse Practitioner 7 National Government Services, Inc.

Acronyms NUBC National Uniform Billing Committee OSC Occurrence Span Code PA Physician Assistant PHP Partial Hospitalization Program PSC Patient status code RTP Return to provider SAD Self-administered drugs SIA Supplemental Instructions article TOB Type of bill 8 National Government Services, Inc.

Objectives Provide high-level overview of PHP coverage guidelines Provide instructions for submitting PHP claims Provide instructions for submitting interim PHP claims effective 04/01/13 per CR 8048 9 National Government Services, Inc.

Agenda Partial hospitalization program Coverage guidelines Billing requirements Payment Interim billing Consistency editing Resources What you should do now Wrap up Questions and answers 10 National Government Services, Inc.

Partial Hospitalization Program (PHP) and PHP Coverage Guidelines

Partial Hospitalization Program Distinct and organized intensive treatment program for patients who would otherwise require inpatient psychiatric care May be covered under Medicare Part B when provided by a HOPD (including a CAH) or a Medicare-certified CMHC Closely resembles highly structured shortterm hospital inpatient program 12 National Government Services, Inc.

Polling Question #1 Please indicate the facility type for which you submit PHP claims to Medicare 1. Community mental health center 2. Critical access hospital 3. Outpatient hospital 13 National Government Services, Inc.

PHP Services Partial hospitalization services Active treatment Incorporate individualized treatment plan Describes coordination of services around patient s needs Includes a multidisciplinary team approach under direction of a physician Reflect high degree of structure and scheduling Treatment goals should be Measurable, functional, time-framed, medically necessary, and directly related to reason for admission 14 National Government Services, Inc.

Patient PHP Eligibility Criteria Patients admitted to a PHP Must be under care of a physician who certifies need Require minimum 20 hours/week therapeutic services Require comprehensive, structured, multimodal treatment Requiring medical supervision and coordination Provided under an individualized plan of care Because of a mental disorder (mental health diagnosis) which severely interferes with multiple areas of daily life Must be able to participate in treatment and tolerate intensity of PHP 15 National Government Services, Inc.

PHP Covered Services Individual or group psychotherapy Occupational therapy Services of staff Drugs and biologicals; not self-administered Individualized activity therapies; not recreational Family counseling services Patient training and education Medically necessary diagnostic services related to mental health treatment 16 National Government Services, Inc.

Did You Know PHP services must be vigorous and proactive as opposed to passive and custodial. It is the need for intensive, active treatment to maintain a functional level and to prevent relapse or hospitalization that qualifies the patient to receive PHP services. 17 National Government Services, Inc.

PHP - Reasonable and Necessary Provides for diagnosis and active, intensive treatment of patient s serious psychiatric condition Reasonably expected to improve or maintain condition and functional level and prevent relapse or hospitalization Overall intent to treat serious psychiatric symptoms Continued treatment to maintain stable psychiatric condition/functional level requires evidence that less intensive options cannot provide necessary support PHP patient does not require 24-hour supervision 18 National Government Services, Inc.

Did You Know Patients who do not meet the degree of severity of illness for the PHP may still require the professional services of psychiatrists and psychologists. Patients in a PHP may be discharged by stepping up to an inpatient LOC (required for patients needing 24-hour supervision) or stepping down to a less intensive treatment (patient s condition improves). 19 National Government Services, Inc.

Noncovered Services Benefit category denials (not appealable) Day care programs Programs attempting to maintain psychiatric wellness Patient psychiatrically stable; requires medication only Coverage denials (not appealable) Services to hospital inpatients Meals, SADs, transportation Vocational training 20 National Government Services, Inc.

Noncovered Services Reasonable and necessary denials (appealable) Patients who cannot, or refuse to participate with active treatment Treatment of chronic conditions without acute exacerbation of symptoms 21 National Government Services, Inc.

Documentation and Physician Supervision Initial psychiatric evaluation/certification Upon admission, a certification by physician must be made that patient would require inpatient psychiatric hospitalization if PHP were not provided Should identify diagnosis and psychiatric need for PHP 22 National Government Services, Inc.

Documentation and Physician Supervision Physician recertification including: Physician signature Timing Content Patient s psychiatric symptoms Patient s response and treatment goals 23 National Government Services, Inc.

Documentation and Physician Treatment plan Supervision Prescribed and signed by a physician Identifies treatment goals Describes a coordination of services Structured to meet needs of patient Includes a multidisciplinary team approach to patient care Documents ongoing efforts to restore patient to a higher level of functioning that would permit discharge or Reflects continued need for intensity of active therapy to maintain individual s condition and functional level and to prevent relapse or hospitalization 24 National Government Services, Inc.

Documentation and Physician Supervision Goals of treatment plan Directly address presenting symptoms Basis for evaluating patient s response to treatment Designed to measure patient s response to active treatment 25 National Government Services, Inc.

Documentation and Physician Supervision Progress notes; should include: Description of nature of treatment service Patient s response to therapeutic intervention and its relation to goals indicated in treatment plan 26 National Government Services, Inc.

Did You Know If all PHP program and patient eligibility requirements are met, including reasonable and necessary requirements, PHP services are an unlimited benefit for a Medicare beneficiary. 27 National Government Services, Inc.

PHP Coverage References CMS CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.3 National Government Services LCD 26398 & SIA A45932 LCD & Article for PHPs http://ngsmedicare.com > Coverage Determinations > Medical Policy Center 28 National Government Services, Inc.

Billing Requirements

Polling Question #2 Please indicate how long you have been submitting PHP claims to Medicare 1. Less than one year 2. Between one year and four years 3. Five years or more 30 National Government Services, Inc.

PHP Billing Requirements Claim Forms and Fields PHP facility services Beneficiary must have Medicare Part B Billed to Part A MAC on CMS-1450/UB-04 claim form or electronic equivalent Professional services provided in PHP Beneficiary must have Medicare Part B Billed to Part B MAC on CMS-1500 claim form or electronic equivalent 31 National Government Services, Inc.

PHP Billing Requirements Claim Forms and Form Locators Claim form UB-04/CMS-1450 Complete all applicable claim fields of claim form FL 1 through FL 80 Many are self-explanatory such as Beneficiary s identifying information Provider s identifying information Others require explanation 32 National Government Services, Inc.

PHP Billing Requirements Claim Form and Form Locators CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 Each FL states required or situational Required - CMS requires Situational - CMS requires, if applicable 33 National Government Services, Inc.

PHP Billing Requirements Claim Form and Form Locators Form Locator Definition 4 TOB 6 Statement covers period claim s from/through dates 17 PSC 18-28 CC 35-36 OSC with from/through date 42 Revenue code 34 National Government Services, Inc.

PHP Billing Requirements Claim Form and Form Locators Form Locator Description 44 HCPCS/Rates/HIPPS rate codes 45 LIDOS 46 Units of service 47 Total charges 48 Noncovered charges 67 Principal diagnosis code 67A-Q Other diagnosis codes 35 National Government Services, Inc.

PHP Billing Requirements Claim Form and Form Locators Claim codes are available from NUBC (http://www.nubc.org) via NUBC s Official UB-04 Data Specifications Manual 36 National Government Services, Inc.

PHP Billing Requirements - TOB Hospital outpatient TOB 13X CAH outpatient TOB 85X CMHC TOB 76X 37 National Government Services, Inc.

PHP Billing Requirements CC 41 Hospitals & CAHs Report CC 41 on claims CMHCs Indicates PHP services Do not report CC 41 on claims 38 National Government Services, Inc.

PHP Billing Requirements Revenue Codes and Charges Report revenue code(s) and associated charge(s) for each individual service component billing Component billing assures that only those services covered under PHP benefit are paid 39 National Government Services, Inc.

Acceptable Revenue Codes Revenue Code Description 0250 Drugs & biologicals 043X Occupational therapy 0900 Behavioral health treatment/services 0904 Activity therapy 0914 Individual therapy 0915 Group therapy 0916 Family therapy 0918 Testing 0942 Education training 40 National Government Services, Inc.

PHP Billing Requirements CPT/HCPCS Codes HOPDs and CMHCs Report CPT/HCPCS codes CAHs Not required to report CPT/HCPCS codes 41 National Government Services, Inc.

Acceptable CPT/HCPCS Codes CMHCs and hospitals other than CAHs are also required to report appropriate HCPCS as follows: Revenue Code 043x CPT/HCPCS Code(s) G0129 0900 90791 or 90792 0904 G0176 0914 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865, or 90880 0915 G0410 or G0411 0916 90846 or 90847 0918 96101, 96102, 96103, 96116, 96118, 96119, or 96120 0942 G0177 42 National Government Services, Inc.

HCPCS Codes Definitions CMHCs and hospitals other than CAHs are also required to report appropriate HCPCS as follows: HCPCS Code Definition G0129 G0176 Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more) Activity therapy, such as music, dance, art or play therapies not for recreation, related to care and treatment of patient s disabling mental problems, per session (45 minutes or more) 43 National Government Services, Inc.

HCPCS Codes Definitions CMHCs and hospitals other than CAHs are also required to report appropriate HCPCS as follows: HCPCS Code Definition G0177 Training and educational services related to the care and treatment of patient s disabling mental health problems, per session (45 minutes or more) 44 National Government Services, Inc.

CPT Codes Definitions CMHCs and hospitals other than CAHs are also required to report appropriate HCPCS as follows: CPT Code Definition 90791 Psychiatric diagnostic evaluation (no medical services) completed by a nonphysician 90792 Psychiatric diagnostic evaluation (with medical services) completed by a physician 45 National Government Services, Inc.

Did You Know CR 8141 advised providers that several revisions were made to the PHP billing code set effective January 1, 2013. 46 National Government Services, Inc.

Did You Know Professional services of physicians and other practitioners provided in HOPDs (including CAHs) for OP PHP patients are separately covered and billed to the Part B MAC The following direct professional services are not paid as PHP services: Physician services that meet criteria for payment on a fee schedule basis PA services NP and CNS services Clinical psychologist services 47 National Government Services, Inc.

PHP Billing Requirements Service Units Hospitals and CMHCs Report number of times service/procedure (as defined by CPT/HCPCS code) was performed CAHs Report number of times revenue code visit was performed Note: Service units not required for drugs/biologicals revenue code 0250 48 National Government Services, Inc.

Reporting Service Units Example Patient received psychological testing CPT code 96100 (defined in one-hour intervals) for a total of three hours during one day Hospital and CMHC report Revenue code 0918, CPT code 96100 and 3 units CAH reports Revenue code 0918, 1 unit (leave CPT code FL blank) 49 National Government Services, Inc.

PHP Billing Requirements LIDOS Reporting Hospitals (other than CAHs) and CMHCs Required to report LIDOS per revenue code line for PHP claims Each service/revenue code provided must be repeated on separate line with specific DOS for each occurrence 50 National Government Services, Inc.

LIDOS Reporting Example Each service must be repeated on a separate line with specific DOS for every occurrence This example is for group therapy services provided twice during a billing period: Revenue Code HCPCS Code Date of Service Units Total Charges 0915 G0176 20130101 1 $80.00 0915 G0176 20130115 2 $160.00 51 National Government Services, Inc.

PHP Billing Requirements Diagnosis Report mental health diagnosis for PHP patients Refer to LCD 26398 52 National Government Services, Inc.

PHP Billing Requirements References CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2.3 (CMS will update per CR 8048) Chapter 4 Section 260 Chapter 25, Section 75 National Government Services LCD 26398 & SIA A45932 LCD & Article for PHPs http://ngsmedicare.com > Coverage Determinations > Medical Policy Center 53 National Government Services, Inc.

Payment CMHC CMHC PHP APCs: APC Group Title 0172 0173 Level I Partial Hospitalization (3 services) for CMHCs Level II Partial Hospitalization (4 or more services) for CMHCs 54 National Government Services, Inc.

Payment Hospital Hospital-based PHP APCs: APC 0175 0176 Group Title Level I Partial Hospitalization (3 services) for hospital-based PHPs Level II Partial Hospitalization (4 or more services) for hospital-based PHPs 55 National Government Services, Inc.

Payment CAH Payment to CAHs made on reasonable cost basis 56 National Government Services, Inc.

Beneficiary Cost-Sharing Medicare Part B deductible and coinsurance apply to PHP claims 57 National Government Services, Inc.

Did You Know Payment may be made for covered diagnostic/therapeutic services furnished by CSWs in a hospital outpatient setting. CSW services furnished under a PHP are included in the PHP reimbursement rate. Other CSW services must be billed to the Part B MAC on a CMS-1500 claim form. 58 National Government Services, Inc.

Interim Billing Frequency of Billing for PHP

PHP Interim Billing CR 8048, Enforcing Interim Billing for PHP Services Effective date 01/01/13 Implementation date 04/01/13 60 National Government Services, Inc.

PHP Interim Billing Beginning 04/01/13, Medicare will enforce interim billing of claims for PHP services Medicare requires that claims for PHP services be submitted in DOS order (interim or sequential billing) Applies to TOBs: 13X (hospital outpatient) with CC 41 85X (CAH) with CC 41 76X (CMHC) 61 National Government Services, Inc.

Did You Know In the CY 2013 Physician Fee Schedule final rule, CMS created a new G-code that will be used to report physician (or qualifying nonphysician practitioner) care management services for a patient following a discharge from a PHP. Crucial to this implementation, is correct interim billing of PHP services. 62 National Government Services, Inc.

PHP Interim Billing Frequency Digit in TOB To determine out of sequence claim submission for outpatient course of treatment, provider must utilize correct frequency digit in TOB 63 National Government Services, Inc.

PHP Interim Billing Frequency Digit in TOB = 1 If from/through dates on claim include dates for all services of course of treatment Frequency digit in TOB is 1 Admit through discharge claim (i.e., 131, 761, or 851) Final PSC 64 National Government Services, Inc.

PHP Interim Billing Frequency Digit in TOB = 2 If from/through dates on claim include DOS at start of course of treatment and additional services are expected to be submitted on a subsequent bill Frequency digit in TOB is 2 First interim claim (i.e., 132, 762, or 852) PSC 30 65 National Government Services, Inc.

PHP Interim Billing Frequency Digit in TOB = 3 If from/through dates on claim include services neither at start or completion of course of treatment and additional services are expected to be submitted on a subsequent bill Frequency digit in TOB is 3 Interim continuing claim (i.e., 133, 763, or 853) PSC 30 66 National Government Services, Inc.

PHP Interim Billing Frequency Digit in TOB = 4 If from/through dates on claim include DOS at completion of course of treatment and no additional services are expected to be submitted on a subsequent bill Frequency digit in TOB is 4 Interim last claim (i.e., 134, 764, or 854) Final PSC 67 National Government Services, Inc.

Did You Know Providers may submit interim bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the TOB and sequentially. 68 National Government Services, Inc.

PHP Interim Billing Other Services Rendered During PHP LOA carve out process applies Continue to submit interim PHP claims even if non- PHP services rendered during PHP claim from/through dates For example, inpatient stay, outpatient services, or outpatient service subject to OPPS Report OSC 74 on PHP claim with LOA dates From/through dates for when non-php services are provided during PHP claim from/through dates See example in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2.2 69 National Government Services, Inc.

PHP Interim Billing Consistency Editing FISS will enforce consistency editing for PHP services from hospitals, CAHs and CMHCs To ensure that outpatient providers submit claims for a continuing course of treatment for a patient in DOS sequence Bills submitted out of sequence will be RTP 70 National Government Services, Inc.

Resources

Resources CMS IOMs Web page http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html Publication 100-02, Medicare Benefit Policy Manual Chapter 6, Section 70, 70.1 and 70.3 Chapter 15, Section 170 Publication 100-04, Medicare Claims Processing Manual Chapter 1, Section 50.2.2 and 50.2.3 Chapter 4, Section 260 Chapter 25, Section 75 72 National Government Services, Inc.

Resources CMS Transmittals Web page http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/index.html CR 8141 http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R2611CP.pdf CR 8048 http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R2578CP.pdf 73 National Government Services, Inc.

Resources CMS Medlearn Matters Web page http://www.cms.gov/outreach-and-education/medicare- Learning-Network-MLN/MLNGenInfo/ MM8141 http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNMattersArticles/Downloads/MM8141.pdf MM8048 http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNMattersArticles/downloads/MM8048.pdf 74 National Government Services, Inc.

Resources National Government Services LCD 26398 & SIA A45932 LCD & Article for PHPs http://ngsmedicare.com > Coverage Determinations > Medical Policy Center 75 National Government Services, Inc.

Resources Mental Health Services Booklet ICN 903195, revised March 2012 http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Mental_Health _Services_ICN903195.pdf 76 National Government Services, Inc.

What You Should Do Now Share presentation with coworkers who could not attend Submit claims in accordance with Medicare coverage and billing guidelines Ensure proper interim billing Be familiar with resources Attend future education 77 National Government Services, Inc.

Wrap Up

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Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at http://www.ngsmedicare.com Topic = J13: Partial Hospitalization Program Interim Billing Guidelines Medicare University Credits (MUCs) = 2 Catalog Number = Sent via e-mail Course Code = Sent via e-mail For step-by-step instructions on self-reporting please visit http://www.ngsmedicare.com > Medicare University > Accessing the Self-Reporting Tool 82 National Government Services, Inc.

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