Partial Hospitalization Program Billing Requirements

All charges submitted by a hospital, critical access hospital (CAH) and/or community mental health center (CMHC) will appear under one of the types of bill (TOB) shown below.

Outpatient Hospital

CAH

CMHC

Sequential Billing

Partial hospitalization program (PHP) claims must be submitted in sequence for a continuing course of treatment.

• If a patient completes their course of treatment in the same month, submit your claim with TOB for admission through discharge (131, 851, or 761).
• If the patient does not complete their course of treatment in the same month, submit your claim using the TOB for 1st interim claim (132, 852, or 762).
• If the patient does not complete their course of treatment in the subsequent month, submit your claim using the TOB for continuing claim (133, 853, or 763).

Use the continuing claim TOB until the last month of treatment. Submit the last month of treatment with TOB 134, 854 or 764.

Medicare systems will enforce the consistency editing for interim billing of claims for PHP services.

Condition Code

All hospitals, including CAHs, report condition code 41 to indicate the claim is for partial hospitalization services.

Occurrence Span Code

If a PHP patient is admitted as an inpatient or receives other outpatient non-PHP services, please report occurrence span code 74 with the dates the patient was an inpatient in the hospital or received other outpatient non-PHP services on your monthly sequential claim.

Revenue Codes

HCPCS Codes

Line Item Date of Service Reporting

Hospitals, other than CAHs, and CMHCs are required to report line item dates of service (LIDOS) on each revenue code line.

Each service/revenue code provided must be repeated on a separate line item along with the specific DOS for each occurrence.

Professional Services

The professional services listed below are separately covered and paid as the professional services of physicians and other practitioners. 

These practitioners (other than physician assistant (PA)) bill directly for the professional services furnished to hospital and CMHC partial hospitalization patients.

• The professional services of a PA can be billed only by the PAs employer.
• Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;
• PA services as defined in §1861(s)(2)(K)(i)
• Nurse practitioner and clinical nurse specialist services, as defined in §1861(s)(2)(K)(ii)
• Clinical psychologist services as defined in §1861(ii)

The services of other practitioners (including clinical social workers and occupational therapists) are bundled when furnished to hospital and CMHC patients. These nonphysician practitioner services are billed as partial hospitalization services.

References

• IOM Pub. 100-04, Claims Processing Manual, Chapter 4, Section 260