Partial hospitalization is a time limited, structured program of multiple and intensive psychotherapy and other therapeutic services provided by a multidisciplinary team, as defined by Medicare, and provided in an outpatient hospital facility or community mental health center (CMHC) that meets Medicare requirements to provide partial hospitalization programs services. The goal of the partial hospitalization program is to resolve or stabilize an acute episode of mental illness.
To be a partial hospitalization provider, an outpatient hospital or a CMHC must:
• Be certified by Medicare to provide partial hospitalization
• Receive approval from DHS
Providers must follow Medicare guidelines for partial hospitalization program content, physician certification requirements, and documentation.
To receive partial hospitalization program services, a recipient must:
• Be eligible for Minnesota Health Care Programs
• Be experiencing an acute episode of mental illness that meets the criteria for an inpatient hospital admission
• Have appropriate family or community resources needed to support and enable the recipient to benefit from less than 24-hour care
• Be referred for partial hospitalization by a physician for an outpatient hospital program, or by a physician, LICSW, or LP for a community mental health center program
• Have a completed LOCUS assessment with a Level 4 indication for adults age 18 and older
Partial hospitalization may be used as a step down from an inpatient mental health stay or in lieu of an inpatient psychiatric stay, when medically appropriate.
Partial hospitalization includes, at a minimum, one session of individual, group, or family psychotherapy and two or more other services (such as activity therapy or training and education).
To be consistent with Medicare recommended standards:
• Provide at least 4 days but not more than 5 out of 7 calendar days of partial hospitalization program services
• Ensure a minimum of 20 service components and a minimum of 20 hours in a 7 calendar day period
• Provide a minimum of 5 to 6 hours of services per day for an adult age 18 years or over
• Provide a minimum of 4 to 5 hours of services per day for a child under age 18 years
Use the MN–ITS 837I to bill for partial hospitalization program services.
• Indicate the patient status information as continuing service; indicating discharge instead of continuing service may deny the claim
• Enter the type of bill (TOB) 13X Outpatient
• Enter the type of bill (TOB), 76X Community Mental Health Center (CMHC)
• Use revenue code 0912
• Use revenue code 0913
• Use procedure code H0035 or H0035 HA for children/adolescent services
Therapy outside the partial hospitalization program is covered only for physician services and medication management:
• Bill using MN–ITS 837P
• Bill visits using the appropriate E/M code
• Enter place of service 22 (outpatient hospital) or 53 (CMHC)
If the purpose of the visit is to provide psychotherapy only or hybrid psychotherapy/E/M services, the appropriate psychotherapy codes require compliance with the authorization requirements.
A recipient may receive up to 21 calendar days of partial hospitalization program services without authorization.
Submit an authorization request with supporting documentation of medical necessity for:
• Services provided after the 21st day (beginning the 22nd day) following admission; Medicare guidelines require physician re-certification by the 18th day
• Providing fewer than five hours of partial hospitalization per day for an adult age 18 years or over; or fewer than four hours of partial hospitalization per day for a child under age 18 years (circumstances, such as when a recipient is unable to tolerate a full day, are rare that a recipient would require fewer or reduced services on any given day)
• Readmission within 45 days of a previous discharge (most individuals will not experience a second acute episode of mental illness within 45 days of discharge from a partial hospitalization program)
• An authorization may be needed when an Intensive Residential Treatment Services (IRTS) provider received payment for same day service as the PHP and the PHP was denied. Although an IRTS provider must seek prior authorization for providing intensive rehabilitative mental health services to a resident of the IRTS when the resident participates in a partial hospitalization program on the same day, claims are paid on a first in, first paid basis. If the PHP receives a denial for this reason, the partial provider should first contact the IRTS provider to coordinate care if not already in progress and submit a request to the medical review agent for authorization of the PHP for that day.
• An authorization is required for partial hospitalization when a recipient is receiving concurrent DBT (Dialectical Behavior Therapy) services.
MN Rules Parts 9505.0370 to 9505.0372
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United States Code, title 42, chapter 7, subchapter XVIII, section 1395x, (ff),