90875
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.20
Facility
$51.44
Non-Facility
$60.46
Documentation Required
- Billing, coding, and required claim documentation must follow the requirements specified in LCD L37633 (see that LCD for required medical records, prior authorization, and claim submission documentation).
- Treating physician must certify the need for the structured combination of services provided by the PHP.
- An individualized treatment plan is required that describes coordination of services, includes measurable, functional, time-framed medically necessary goals, and reflects a multidisciplinary team approach under physician direction.
- Progress notes must document vigorous, proactive active treatment (not passive or custodial) and demonstrate patient participation and clinical progress toward goals.
Key Coverage Criteria
- Partial Hospitalization Program services that meet the coverage criteria of Local Coverage Determination L37633 are considered covered.
- Coverage is allowed when the patient is discharged from an inpatient psychiatric hospitalization and PHP is used in lieu of continued inpatient treatment with evidence of need for the acute, intense, structured combination of services provided by PHP.
- Coverage is allowed for patients who, in the absence of PHP, would be at reasonable risk of requiring inpatient hospitalization — typically with acute onset or decompensation of a covered Axis I disorder that severely interferes with multiple areas of daily life and requires a multidisciplinary, intensive, structured program but not 24-hour inpatient supervision.
- Coverage requires that the PHP deliver active, vigorous, proactive, individualized treatment directed by a physician with measurable, functional, time-framed, medically necessary goals expected to improve or maintain condition and prevent relapse or hospitalization.
- Coverage is for admission whose overall intent is to treat serious presenting psychiatric symptoms and not primarily to provide maintenance, custodial, recreational, or diversionary activities.
- Treatment: Pharmacotherapy for the treatment of bulimia (e.g., selective serotonin reuptake inhibitors such as fluoxetine, tricyclic anti-depressants, trazodone, topiramate).
20 Active Policies
AMBETTER-CP.BH.300 — Biofeedback for Behavioral Health Disorders
A56685 — Billing and Coding: Partial Hospitalization Programs
L37633 — Partial Hospitalization Programs
AETNA-CPB-0504 — Hyperhydrosis
AETNA-CPB-0511 — Eating Disorders
Related Codes
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