Billing and Coding: Psychiatric Partial Hospitalization Programs

Medicare covers Psychiatric Partial Hospitalization Program services when a physician certifies that the patient would otherwise require inpatient psychiatric hospitalization and the patient receives active treatment under an individualized written treatment plan developed by a physician with a multidisciplinary team. Coverage requires specific documentation including an initial psychiatric evaluation placed in the chart within 48 hours of admission, timely physician recertifications (first at day 18 and then at least every 30 days), a treatment-plan review at least every 31 days, separate progress notes for each billed service, and a valid ICD-10-CM diagnosis on the claim. Billing must comply with ABN/modifier and claim submission requirements (e.g., CMS-R-131, occurrence code 32, and use of modifiers GA/GX/GY/GZ with attendant automatic-denial rules).

"Patient is admitted to a Psychiatric Partial Hospitalization Program (PHP) when a physician certifies that, absent PHP services, the patient would require inpatient psychiatric hospitalization."