LCD L37633

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

Title XVIII of the Social Security Act, §1835(a) references physician certification.

Title XVIII of the Social Security Act, §1861(ff) and §1832(a) define the partial hospitalization benefit and provide for coverage of partial hospitalization in a hospital or community mental health center (CMHC) setting.

Title XVIII of the Social Security Act, §1861(s) and (t) outline coverage for drugs and biologicals and services and supplies.

Title XVIII of the Social Security Act, §1861(s)(2)(B) references partial hospitalization in a hospital outpatient setting.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §70 Outpatient Hospital Psychiatric Services

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §70.1 Consultations With a Beneficiary's Family and Associates

Indications and Limitations of Coverage

Overview

• Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services. The treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. Programs providing primarily social, recreational or diversionary activities are not considered partial hospitalization.

• Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary and directly related to the reason for admission.

• Eligibility for Medicare coverage of a PHP comprise 1 of 2 groups:

• Patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment. Where partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP.

• Patients who in the absence of partial hospitalization would be at reasonable risk of requiring inpatient hospitalization.

• Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial. Patients must also have the need for the active treatment provided by the program of services. It is the need for intensive, active treatment of his/her condition to maintain a functional level and to prevent relapse or hospitalization, which qualifies the patient to receive the services.

• This program of services provides for the diagnosis and active, intensive treatment of the individual’s serious psychiatric condition and in combination, are reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization. A particular individual covered service (described below) as intervention, expected to maintain or improve the individual’s condition and prevent relapse, may also be included within the plan of care (POC), but the overall intent of the partial program admission is to treat the serious presenting psychiatric symptoms. Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent hospitalization.

• Patients admitted to a PHP do not require 24 hour per day supervision as provided in an inpatient setting and must have an adequate support system to sustain/maintain themselves outside the PHP. Patients admitted to a PHP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association (APA) or listed in Chapter 5 of the most current edition of the International Classification of Diseases (ICD). The disorder severely interferes with multiple areas of daily life. The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from participating in an active treatment program. The treating physician must certify the need for the structured combination of services provided by the program. This active treatment is required to appropriately treat the patient’s presenting psychiatric condition.

Covered Services

Items and services that can be included as part of the structured, multimodal active treatment program include:

• Individual or group psychotherapy with physicians, psychologists or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);

• Occupational therapy (OT) requiring the skills of a qualified occupational therapist. OT, if required, must be a component of the physicians treatment plan for the individual;

• Services of other staff (social workers, psychiatric nurses and others) trained to work with psychiatric patients;

• Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes;

• Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;

• Family counseling services for which the primary purpose is the treatment of the patient’s condition;

• Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and

• Medically necessary diagnostic services related to mental health treatment.

Limitations

Noncovered Services-Benefit category Denials

• Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care

• Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill

• Patients who are otherwise psychiatrically stable or require medication management only

Noncovered Services-Coverage Denials

• Services to hospital inpatients

• Meals, self-administered medications, transportation

• Vocational training

Noncovered-Reasonable and Necessary Denials

• Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP

• Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

Initial Psychiatric Evaluation/Certification

Upon admission, a certification by the physician must be made that the patient admitted to the PHP would require inpatient psychiatric hospitalization if the partial hospitalization services were not provided. The certification should identify the diagnosis and psychiatric need for the partial hospitalization. Partial hospitalization services must be furnished under an individualized written POC, established by the physician, which includes the active treatment provided through the combination of structured, intensive services that are reasonable and necessary to treat the presentation of serious psychiatric symptoms and to prevent relapse or hospitalization.

Physician Recertification Requirements

• Signature – The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient’s response to treatment.

• Timing – The first recertification is required as of the 18 th calendar day following admission to the PHP. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days.

• Content – The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the PHP and describe the following:

- The patient’s response to the therapeutic interventions provided by the PHP;

- The patient’s psychiatric symptoms that continue to place the patient at risk of hospitalization, and;

- Treatment goals for coordination of services to facilitate discharge from the PHP.

Treatment Plan

Prescribed and signed by the physician, which

• identifies treatment goals

• directly addresses the presenting symptoms

• evaluates response to treatment

• measures responses to treatment

• describes coordination of services

• meets particular needs of patient, including multidisciplinary team approach

• documents ongoing efforts to restore the individual patient to a higher level of functioning that would permit discharge from the program, or reflect the continued need for the intensity of care required by PHP

Progress Notes

Should include:

• A description of the nature of the treatment service

• The patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan

• Correlation with services billed

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

Association for Ambulatory Behavioral Healthcare (AABH). An Overview of the Partial Hospitalization Modality. Accessed June 30, 2020.

Gartner L, Mee-Lee D. The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders: Treatment Improvement Protocol Series 13. Rockville, MD: Center for Substance Abuse Treatment; 1995.

Nyman G, Harbin H, Book J, et al. Green spring criteria for medical necessity of the outpatient treatment and its use in the mental health utilization review program. Qual Assur Util Rev. 1992;7(2):65-69.

U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Accessed June 30, 2020.