Description:
This policy addresses reimbursement for psychiatric and substance use services including Intensive Outpatient Program, Partial Hospitalization Program and Residential Treatment Center.
Definitions:
Facility/type of service
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Definition
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Intensive Outpatient Program
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A structured, short-term multidisciplinary treatment for psychiatric illness and/or substance use provided by a Health Care Provider. The treatment is more intensive than Outpatient treatment but less intensive than Partial Hospitalization.
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Partial Hospital Program
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Continuous structured multidisciplinary treatment of mental illness or substance use by a Health Care Provider, usually held during the daytime hours and generally providing 20 or more hours per week to treat multidimensional instability not requiring 24-hour care.
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Residential Treatment Center
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24-hour care under the clinical supervision of a Health Care Provider, in a residential treatment center other than an acute care hospital, for the active treatment of chemically dependent or mentally ill persons and to stabilize multidimensional imminent risk.
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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) 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. This includes all services and disciplines including therapies, social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, 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 used in the RTC program, such as room and board, lab, all therapies and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dietitians, 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.
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.
Billing Instructions:
Different levels of psychiatric and substance use services are provided by facilities with various types of licensure. 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.
Psychiatric Services
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Facility/type of service
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Type of Bill
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Revenue code
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Level
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HCPCS
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Modifier
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Intensive Outpatient Program
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131
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0905
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N/A
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S9480
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N/A
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Partial Hospitalization Program
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131
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0912
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Full day
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H0035
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N/A
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131
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0912
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Eating Disorder Program
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S9485
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N/A
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Residential Treatment Center
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86X
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1001
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N/A
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T2048
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N/A
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Substance Use Services
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Facility/type of service
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Type of Bill
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Revenue code
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HCPCS
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Intensive Outpatient Program
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131
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0905
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H0015
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Partial Hospitalization Program
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131
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0912
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S9475
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Residential Treatment Center
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86X
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1002
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H2036
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Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
History:
Date
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Updates
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04/16/2020
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Created Psychiatric and Substance Use Services reimbursement policy
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12/22/2020
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Removed reference to age specific reimbursement for PHP. Age specific reimbursement is no longer in effect with the implementation of EAPG pricing. Please reference the fee schedule for age specific rates prior to EAPG implementation. Updated language about what is included in the per diem payment for each level of care.
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1/26/2021
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Added additional information regarding services that can be billed separately while in PHP or RTC setting.
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