Description:

This policy addresses reimbursement for psychiatric and substance use services including Intensive Outpatient Program, Partial Hospitalization Program and Residential Treatment Center.

Definitions:

Policy:

Intensive Outpatient Program (IOP) services are paid on the lesser of charges or a per-diem rate.

Partial Hospitalization Program (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.  Reimbursement is age-specific: Child (ages 0 through 12 years), Adolescent (ages 13 through 17 years) and Adult (ages 18 years and older).

Residential Treatment Center (RTC) services are reimbursed on a uniform per-diem basis, and payment are 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 psychologists and psychiatrists inherent to the treatment program, such as group therapy, should not be billed separately. 

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. 

Note: Individual therapy by a psychiatrist, psychologist, testing and labs that are not inherent to the treatment program are reimbursed separately.  Group or family counseling by any discipline cannot be billed in addition to the PHP, RTC or IOP stay. 

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. 

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: