Partial Hospitalization Program

Revised: January 6, 2025

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization Requirements

· Billing

· Legal References

Overview

Partial hospitalization is a time-limited, structured program provided in an outpatient hospital setting or a Medicare-certified community mental health center (CMHC). Partial hospitalization provides person- and family-centered treatment by a multidisciplinary team under the direction of a physician.

Eligible Providers

Outpatient hospital facilities or community mental health centers that meet Medicare requirements to provide partial hospitalization services are eligible to provide partial hospitalization services.

Eligible Members

To receive partial hospitalization program (PHP) services, an MHCP member must:

· Be eligible for MHCP

· Be experiencing an acute episode of mental illness that meets the criteria for an inpatient hospital admission

· Have the ability to participate in treatment

· Have appropriate family or community resources needed to support and enable the member to benefit from less than 24-hour care

· Be admitted to PHP under the care of a physician who certifies the need for partial hospitalization, stating the member would otherwise require inpatient psychiatric care, if PHP were not provided.

· Have a completed Level of care assessment with a Level 4 indication for adults aged 18 and older

Covered Services

Partial hospitalization includes, at a minimum, one session of individual, group or family psychotherapy and two or more other service components.

· Individual and group psychotherapy

· Occupational therapy services are covered if the member requires the skills of a qualified occupational therapist and be performed by or under the supervision of a qualified occupational therapist or by an occupational therapy assistant.

· Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients.

· Drugs and biologicals furnished to outpatients for therapeutic purposes, but only if they cannot be self-administered.

· Activity therapies but only those that are individualized and essential for the treatment of the member's condition. The treatment plan must clearly justify the need for each particular therapy utilized and explain how it fits into the patient's treatment.

· Family counseling services only where the primary purpose of such counseling is the treatment of the patient's condition.

· Patient education programs, but only where the educational activities are closely related to the care and treatment of the patient.

To be consistent with Medicare recommended standards:

· Provide at least four days, but not more than five out of seven calendar days, of partial hospitalization program services

· Ensure a minimum of 20 service components and a minimum of 20 hours in a seven-calendar-day period

· Provide a minimum of five to six hours of services per day for an adult aged 18 years or older

· Provide a minimum of four to five hours of services per day for a child under age 18 years

Noncovered Services

The following services are not covered by MHCP as partial hospitalization program services.

· Meals and transportation

· Activity therapies, group activities or other services and programs which are primarily recreational or diversional in nature

· Outpatient psychiatric day treatment programs that consist entirely of activity therapies

· Daycare programs

· Psychosocial programs primarily for social or recreational purposes

· Vocational training when the services are related solely to specific employment opportunities, work skills or work settings

Authorization Requirements

A member 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

· Providing fewer than five hours of partial hospitalization per day for an adult age 18 years or older, or fewer than four hours of partial hospitalization per day for a child under age 18 years (Example: circumstances, such as when a member is unable to tolerate a full 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)

Submit all of the following to request authorization from the review agent:

· MHCP Authorization Form (DHS-4695) (PDF) (except when using MN–ITS to request authorization)

· Most current diagnostic assessment

· Individual treatment plan that includes same items as listed under Documentation of Covered Services in the Psychotherapy section of the MHCP Provider Manual

· Discharge plan

· A level of care assessment with a Level 4 indication for adults 18 years old or older

· Most recent progress notes from the last six psychotherapy sessions that include same items as listed under Documentation of Covered Services in the Psychotherapy section of the MHCP Provider Manual

· Must include a statement (signed by a treating physician) that the beneficiary would require inpatient psychiatric care in the absence of partial hospitalization service.

Authorization Requirements for Concurrent Services

Refer to the following when an authorization may be needed or is required:

· 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 member is receiving concurrent DBT (Dialectical Behavior Therapy) services.

· An authorization is required to provide partial hospitalization and residential crisis stabilization services concurrently. The residential crisis stabilization provider should provide a letter or memo of support for the partial hospitalization to submit with an authorization request to the medical review agent. The partial hospitalization provider must obtain authorization when services are provided concurrently with adult residential crisis stabilization services and the member meets at least one of the following:

· Was already attending partial hospitalization services and continuation of these services adds appropriate continuity to their life; or

· Needs intensive therapeutic intervention that the crisis stabilization facility cannot provide and can benefit from more intensive services; or

· Needs specific therapeutic intervention the crisis stabilization program cannot provide (treatment for eating disorders, obsessive or compulsive disorder, and the like); or

· Is transitioning to partial hospitalization services following the stay at the crisis stabilization facility

Billing

Use the MN–ITS 837I to bill for partial hospitalization program services.

Include the following:

· Indicate the appropriate patient status.

· Enter the type of bill (TOB) 13X when billing outpatient hospital facility claims

· Enter the type of bill (TOB) 76X when billing as a Community Mental Health Center (CMHC)

· Enter the type of bill (TOB) 85X when billing as a Critical Access Hospital (CAH)

· Use revenue code 0912 (low intensity) or 0913 (high intensity)

· Use procedure code H0035 for adults or H0035 with modifier HA for children or adolescent services (refer to the following Partial Hospitalization Program table)

· Report the attending provider as the physician who has overall responsibility for the member’s medical care and treatment

Partial Hospitalization Program
Code	Modifier	Description	Units
H0035	No modifier needed	Partial Hospitalization Services – age 18 and over	1 session
H0035	HA	Partial Hospitalization Services – under age 18	1 session

Legal References

Minnesota Statutes, 256B.0671, subdivision 12
Code of Federal Regulations, title 42, section 410.43
Code of Federal Regulations, title 42, section 410.110