Policy
Intensive Outpatient Program (IOP)
IOP services are paid on the lesser of charges or a per-diem rate. Psychotherapy services (individual, family, and group), peer support services and pharmacologic management services completed by any provider type are included in the facility per diem payment. Medication assisted treatment, Office Based Opioid Treatment (OBOT) and Opioid Treatment Programs (OTP), are separately reimbursable.
Partial Hospitalization Program (PHP)
PHP services are reimbursed the lesser of charges or an all-inclusive per diem payment that includes services used in the program. The per-diem rate includes all services routinely used in the PHP program Services provided by medical professional employed by or contracted with the PHP are part of the all-inclusive per diem rate and cannot be billed separately. These routine services are made available to all patients entering the facility. Examples of routine services includes all services and disciplines including therapies, social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, peer support, etc.
Psychiatrists, psychologists, psychiatrist nurse practitioner and psychiatrist physician assistant may bill separately on the CMS-1500 Claim Form for services outside of the treatment program such as psychological testing, individual therapy, and E/M services. Appropriate licensed health care providers can also bill separately for labs and psychiatric diagnostic evaluations without medical services. Group or family counseling cannot be billed in addition to the partial hospitalization stay.
Residential Treatment Center (RTC)
RTC services are reimbursed on a uniform per-diem basis, and payment is based on the lesser of charges or the per-diem rate. The per-diem rate includes all services routinely used in the RTC program. Services provided by medical professional employed by or contracted with the RTC are part of the all-inclusive per diem rate and cannot be billed separately. These routine services are made available to all patients entering the facility.
Examples of routine services include room and board, CLIA waived tests, all therapies and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dietitians, peer support, etc. Services by a psychologist, psychiatrist, psychiatrist nurse practitioner and psychiatrist physician assistant inherent to the treatment program, such as group therapy, should not be billed separately on the CMS-1500 Claim Form.
Psychiatrists, psychologists, psychiatrist nurse practitioners and psychiatrist physician assistants may bill separately on the CMS-1500 Claim Form for services outside of the treatment program such as psychological testing, individual therapy, and E/M services. Appropriate licensed health care providers can also bill separately for psychiatric diagnostic evaluations without medical services. Group or family counseling cannot be billed in addition to the RTC stay.
Social Detox
Social detox services are reimbursed on a uniform per-diem basis and payment is based on the lesser of charges or the per-diem rate. Social detox is available for Commercial and Medicaid Expansion effective 1/1/2025. Prior to 1/1/2025 it's only available for Medicaid Expansion.
Leave of Absence
If the patient has a leave of absence (LOA) during the residential treatment stay, the LOA day(s) must be identified with Revenue Code 018X and units equal to the number of LOA days. The following are a couple examples on how to count LOA days:
- If the patient leaves the facility on Saturday afternoon and returns on Sunday afternoon, there is no LOA as the patient received services on both days.
- If the patient leaves the facility on Saturday afternoon and returns on Monday afternoon, one (1) LOA day should be billed.
- When a patient requires inpatient level of care at another medical center an LOA cannot be used. In this scenario, the date the patient left the facility would be the through date on the claim and the appropriate discharge status code must be reported. If the patient returns at an inpatient level of care, a new inpatient claim for the readmission would be submitted.
Coding & Billing Guidelines
Different levels of psychiatric and substance use services are provided by facilities with various types of licensures. Each level of care requires specific billing and coding information, which determines appropriate reimbursement. The billing guidelines for these various levels are listed below. Services must be billed on the UB-04 Claim Form. Report one line per date of service with 1 unit. Any services other than what’s listed below should be billed on the CMS-1500 claim form.
