Psychiatric and Substance Use Services Guidelines

Policy ID: NDRP-BH-002
Section: Behavioral Health
Effective Date: April 05, 2020
Revised Date: April 16, 2020

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

Definition

Intensive Outpatient Program

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.

Partial Hospital Program

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.

Residential Treatment Center

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.

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. 

Psychiatric Services

Facility/type of service

Type of Bill

Revenue code

Level

HCPCS

Modifier

Intensive Outpatient Program

131

0905

N/A

S9480

N/A

Partial Hospitalization Program

131

0912

Full day

H0035

N/A

131

0912

Eating Disorder Program

S9485

N/A

Residential Treatment Center

86X

1001

N/A

T2048

N/A

Substance Use Services

Facility/type of service

Type of Bill

Revenue code

HCPCS

Intensive Outpatient Program

131

0905

H0015

Partial Hospitalization Program

131

0912

S9475

Residential Treatment Center

86X

1002

H2036

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

Updates

04/16/2020

Created Psychiatric and Substance Use Services reimbursement policy