Knowledge Base Article

Senseless massacres and suicides of prominent people in recent years have drawn attention to mental health issues in America. Some in our elderly population face a diagnosis of Alzheimer’s or other forms of dementia as they age. Our youth and all ages are at risk of life-altering drug and alcohol addictions. According to a Washington Post article from 2012, although the United States spends over $113 billion on mental health treatment, that is still not enough to serve all those who need it. Costs, limited access, and attitudes about mental health remain big barriers to treatment. One positive cited by the article is that recent federal legislation requires more expansive insurance coverage for mental health services.

Medicare covers a continuum of mental health services from inpatient hospital services, to partial hospitalization, to outpatient services. The coverage requirements of psychiatric Partial Hospitalization Program services are described in the Medicare Benefits Policy Manual, Chapter 6, section 70.3.

What a PHP Is

“Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.”

What a PHP Is Not

A PHP is not a program that is:

• Comprised primarily of diversionary activity, social, or recreational therapy
• A psychosocial program which provides only a structured environment, socialization, and/or vocational rehabilitation
• Only for monitoring the management of medication for patients whose psychiatric condition is otherwise stable

Patients eligible for a PHP program are patients trying to avoid a new or continued hospitalization for psychiatric services – hence, the need for the acute, intense, structured combination of services provided by a PHP. Patients participating in a PHP program must:

• Be under the care of a physician who certifies the need for PHP
• Have a plan of care that requires at least 20 hours a week of therapeutic services
• Have a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning (generally acute in nature)
• Have an adequate support system to sustain/maintain themselves outside the PHP and must not be an imminent danger to themselves or others
• Be willing and able to participate with active treatment of their mental disorder and tolerate the intensity of a PHP

Medicare recently released a MLN Matters Special Education (SE) Article SE1607 describing edits being implemented to enforce the requirement for a minimum of 20 hours per week of therapeutic services for patients in a Partial Hospitalization Program (PHP). There are three edits that will become effective July 2016:

• IOCE Edit 95 (FISS Reason Code W7095) - Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service
• IOCE Edit 96 (FISS Reason Code W7096) - Partial hospitalization interim claim from and through dates must span more than 4 days
• IOCE Edit 97 (FISS Reason Code W7097) - Partial hospitalization services are required to be billed weekly

Initially all three edits will cause the claim to “return to provider” (RTP) for correction, but beginning with the October 2016 IOCE updates, edit 95 (insufficient hours) will cause the claim to deny.

In addition to the amount of treatment, documentation requirements for a PHP admission include an initial physician certification that identifies the patient’s diagnosis, psychiatric need, and that the patient would require inpatient treatment if not for the PHP. Recertifications, required at day 18 and at least every 30 days after that, describe the patient’s response to treatment, reason for continued need for PHP and goals to facilitate discharge. Patients in a PHP must be under a treatment plan that:

• Is prescribed and signed by a physician,
• Identifies treatment goals that directly address the presenting symptoms and are the basis for evaluation of patient response,
• Describes a coordination of services including a multidisciplinary team approach to patient care, and
• Is individualized and structured to meet the particular needs of the patient.

Documentation must also include progress notes showing the services were provided, the nature of the treatment service, the patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.

Hopefully expanded mental health coverage, growing awareness of mental health issues, and programs such as the partial hospitalization programs will make a positive impact on this country’s mental health. It is an issue that could affect any of us, directly or indirectly. It is a cry for help.