Partial hospitalization program coverage guidelines

Partial hospitalization program services

• Structured to provide intensive psychiatric care through active treatment that utilizes a combination of clinically recognized items and services described in Section 1861 of the Social Security Act
• Treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation
• May be covered under Medicare Part B when provided by a hospital outpatient department (including a critical access hospital) or a Medicare-certified community mental health clinic
• Closely resembles highly structured, short-term hospital inpatient program

Criteria

• Active treatment that incorporates an individualized treatment plan
• Describes a coordination of services wrapped around the particular needs of the patient
• Includes a multidisciplinary team approach to patient care under the direction of a physician
• Reflects a high degree of structure and scheduling
• Treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission

Benefit requirements

• Must be under the care of a physician who certifies the need for services
• Requires a minimum of 20 hours per week of therapeutic services
• Requires comprehensive, structured, multimodal treatment
  • Requiring medical supervision and coordination provided under an individualized plan of care because mental disorder interferes with multiple areas of daily life including social, vocational, and/or educational functioning
    • Generally of an acute nature
    • Must be able to cognitively and emotionally participate in active treatment and tolerate the intensity of the program
• Patients meeting benefit category requirements for partial hospitalization program (PHP) comprise two groups
  • Patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment
  • Patients who, in the absence of partial hospitalization, would be at reasonable risk of requiring inpatient hospitalization
• Recertification must address the continuing serious nature of the patient’s psychiatric condition requiring active treatment in PHP

Covered services

• Individual or group psychotherapy
• Occupational therapy requiring skills of qualified occupational therapist; must be component of treatment plan
• Services of other staff trained to work with psychiatric patients
• Drugs and biologicals not self-administered
• Individualized activity therapies not primarily recreational or diversionary
• Family counseling
• Training and education
• Medically necessary diagnostic services

Partial hospitalization services must be vigorous and proactive as opposed to passive and custodial.

It is the need for intensive, active treatment of the patient's condition to maintain a functional level and to prevent relapse for hospitalization.

Initial evaluation/certification

• Upon admission, a physician must certify that the patient admitted to a PHP would require inpatient psychiatric hospitalization if partial hospitalization services were not provided
• Certification should identify the diagnosis and psychiatric need
• PHP must be furnished under an individualized written plan of care, which includes active treatment through combination of structured, intensive services

Recertification requirements

• Physician signature
• Timing
  • First re-cert by 18th calendar day following admission
  • Subsequent at intervals no less frequently than every 30 days
• Content
  • Patient’s response to therapeutic interventions
  • Patient’s psychiatric symptoms
  • Treatment goals

Treatment plan

• Prescribed and signed by physician
• Identifies treatment goals
• Describes a coordination of services
• Structured to meet needs of patient
• Includes multidisciplinary team approach
• Directly address presenting symptoms
• Designed to measure patient’s response to active treatment
• Document ongoing efforts to restore patient to higher level of functioning that would permit discharge
• Reflect the continued need for the intensity of active therapy to maintain and prevent lapse or hospitalization
• Activities primarily recreational and diversionary or provide level of functional support that does not treat symptoms placing patient at risk, do not qualify as partial hospitalization services

Progress notes

• Include description of the nature of the treatment
• Patient’s response to therapeutic intervention and its relation to goals in treatment plan

Reference

• CMS IOM Publication 100-02, Benefit Policy Manual, Chapter 6, Section 70.3