PHP billing for behavioral health: how partial hospitalization pays.

A Closer Look at PHP Billing for Behavioral Health Service Providers

Partial hospitalization programs treat patients under a psychiatrist’s direction. Their billing terms are in the panel above. America’s mental health problem has been growing steadily over the past few years. More people require mental health services.

What is Partial Hospitalization for Mental Health or Substance Abuse?

Known as PHP, this structured treatment program primarily targets behavioral health patients. It allows patients to continue residing at home while commuting to the treatment facility for up to seven days every week. It’s an alternative to inpatient behavioral health care and more intense than the treatment patients receive in a therapist’s or doctor’s office.

Medicare covers partial hospitalization when a physician certifies that the patient needs it, and a private policy may cover part or all of the cost. The covered PHP services include:

• Individual behavioral training
• Occupational therapy that’s part of the treatment program
• Support groups
• Patients’ training and testing

The Affordable Care Act’s essential health benefit rule lists mental health and substance use disorder services, including behavioral health treatment, as a category that individual and small-group coverage must include. It does not name partial hospitalization: what a plan covers inside that category comes from the state’s benchmark plan and the plan’s own benefit documents.

PHP Billing Requirements

What each payer pays for depends on its own rules. Medicare pays hospital-based PHPs and community mental health center PHPs through separate payment groups. Medicaid programs and commercial plans publish their own hour minimums and authorization steps.

Medicare may cover PHP when a hospital outpatient department or a Medicare-certified community mental health center provides it, and its Benefit Policy Manual (chapter 6, section 70.3) asks for the following:

• A physician certifies at admission that the patient would need inpatient psychiatric hospitalization without PHP and needs at least 20 hours of services a week
• Services follow an individualized written plan of care that a physician establishes and that identifies treatment goals
• Progress notes describe the treatment service, the patient’s response and how it relates to the goals in the treatment plan
• A physician recertifies the need as of the 18th day, then at least every 30 days

Revenue Codes for PHP Billing

PHP billing codes can differ by diagnosis: mental health treatment and substance abuse treatment may be billed differently. For a patient with a dual diagnosis, mental health and substance abuse, only one PHP session per day can be billed.

Here is a quick reference for two PHP code combinations:

S0201 is a generic per-diem PHP code. Its HCPCS descriptor is simply “Partial hospitalization services, less than 24 hours, per diem,” with no reference to substance use. Pairing H0035 with mental health PHP and S0201 with substance use disorder PHP is a payer convention. The codes themselves do not draw that distinction. Which per-diem code a payer expects for a given diagnosis is a question for that payer before the claim goes out.

An incomplete claim can delay or deny reimbursement. Duplicate claims can be denied or delayed: Medicare auto-denies exact duplicates and holds suspected ones for review.

Final Thoughts

Whether a payer will pay for PHP billing for a patient who lives in a residential program is a question for that payer’s own rules. Medicare’s manual says patients admitted to a PHP must have an adequate support system to sustain themselves outside the program, and Indiana Medicaid excludes people who concurrently reside in a group home or other residential care setting from partial hospitalization.

Network status can change the rules too. Tufts Health RITogether, for one, requires out-of-network providers to request prior authorization before starting services, and its grid gives in-network providers different notice and review steps by level of care. That question goes to the payer before billing, with the answer kept in writing.