Description

Partial hospitalization programs (PHP) and intensive outpatient programs (IOP) are outpatient 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 for partial hospitalization and intensive outpatient care according to the criteria outlined in this policy.

Reimbursement Guidelines

Blue Cross NC follows Medicare guidelines for reimbursement of PHP and IOP services. Only one (1) unit of PHP (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 and IOP services are mutually exclusive on the same date of service.

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 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.

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

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 Blue Cross NC Provider Manual
https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/Provider_Manual.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

History

6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 - Routine Policy Review. Minor revisions only. (cjw)

11/1/2025 - Updated Application section to include Healthy Blue + Medicare (HMO-POS D-SNP). Notification on 11/1/2025 for effective date 1/1/2026. (dc)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) 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.