Description

Partial Hospitalization Programs (PHP), Intensive Outpatient Programs (IOP), and Residential Treatment Centers (RTC) are care delivery services for psychiatric and/or chemical dependency, which must be furnished by or under the supervision of registered or licensed personnel and under the direction of a North Carolina licensed physician credentialed by Blue Cross NC.

Policy

Blue Cross NC will reimburse partial hospitalization, residential treatment, and intensive outpatient care according to the criteria outlined in this policy.

Reimbursement Guidelines

Only one (1) unit of PHP (on a facility claim), RTC (on a facility claim) or IOP (on a facility or professional claim), is allowed per date of service as these services are defined as per diem. PHP, RTC and IOP services are mutually exclusive on the same date of service.

Partial Hospitalization Programs (PHP)

PHP (S0201 or H0035) is allowed on facility claims as a per diem and includes all facility, professional, ancillary, and other services rendered to the member.

PHP services will be denied when:

• Billed without a mental health diagnosis as the principal diagnosis.
• Billed with a 'code first' diagnosis as a principal diagnosis and a mental health or substance abuse diagnosis is not also present as a secondary diagnosis on the claim.
• Bill Type 12X (Hospital-Inpatient), 14X (Hospital-Other) is billed with Condition Code 41 (Partial Hospitalization).
• Codes G0129 and G0176 are only used, and therefore reimbursable, for partial hospitalization programs.
• Bill Type 13X is billed with Condition Code 41 (Partial Hospitalization) and the HCPCS code is not present on the approved PHP services list.

Intensive Outpatient Programs (IOP)

IOP is allowed on facility or professional claims as a per diem and includes all facility, professional, ancillary, and other services rendered to the member.

• Report S9480 for intensive outpatient treatment focused on mental health.
• Report H0015 for intensive outpatient treatment focused on substance use disorder(s).

Residential Treatment Centers (RTC)

RTC is allowed on facility claims as a per diem and includes all facility, professional, ancillary, and other services rendered to the member.

Rationale

Partial hospitalization and intensive outpatient programs include, but are not limited to, the following components:

• Assessing the total needs of the member.
• Planning and managing of a member treatment plan involving services where specialized health care knowledge must be applied in order to attain the desired result.
• Observing and monitoring the member’s response to care and treatment.
• Teaching, restoring, and retraining the member.
• Providing directly to the member services requiring specialized education and skills.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

n/a

References

Blue Cross NC Provider Manual

CMS Medicare Claims Processing CMS
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4204CP.pdf

CMS Medicare Benefit Policy CMS
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R10BP.pdf

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT^®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

Medicare Claims Processing Manual, Chapter 4 Medicare Claims Processing Manual (cms.gov)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

History

9/7/21 New policy developed. Notification on 9/7/2021 for effective date 11/16/2021. (eel)

6/1/22 Policy language updated throughout. Reimbursement Guidelines updated with “PHP services will be denied when:…“. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

4/18/2023 Policy name changed from “Partial Hospitalization Intensive Outpatient Programs” to “Facility Behavioral Health”. Residential Treatment Centers (RTC) added to policy. Medical Director Approval. Notification on 4/18/2023 for effective date 06/18/2023.

3/1/2024 Routine policy review. RTC facility reimbursement clarified. Medical Director approved. (ss)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.