Billing instructions for Partial Hospitalization Services provided in Community Mental Health Centers (CMHCs), has been updated based on §4523 of the Balanced Budget Act (BBA) (P.L. 105-33) which requires payment to be made under a prospective payment system for hospital outpatient department services (including partial hospitalization services provided in a hospital outpatient department), as well as application of this prospective payment system to partial hospitalization services furnished by a CMHC. As a result, you must report as follows:

• Report HCPCS codes and modifiers;
• Report line item dates of service; and
• Report in Form Locator (FL) 46 "Service Units" the number of times a particular service or procedure based on the HCPCS was performed instead of the total number of visits for the billing period. These reporting requirements are needed to assure proper payment under the outpatient prospective payment system.

A.    General - Medicare Part B coverage for partial hospitalization services provided by CMHCs is available effective for services provided on or after October 1, 1991.

B.    Special Requirements - Section 1866(e)(2) of the Act recognizes CMHCs as "providers of services" but only for furnishing partial hospitalization services.

C.    Billing Requirements - Bill for partial hospitalization services on Form HCFA-1450 under bill type 76X. Follow bill completion instructions in §416 except for those listed below:

The acceptable revenue codes are as follows:

You are also required to report appropriate HCPCS codes as follows:

Maryland Medicare will edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.

*The definition of code G0129 is as follows: "Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day".

**The definition of code Q0082 has been changed. The new definition is as follows: "Activity therapy furnished as a component of a partial hospitalization treatment program, (e.g., music, dance, art or play therapies that are not primarily recreational), per day."

***The definition of code G0172 is as follows: "Training and educational services furnished as a component of a partial hospitalization treatment program, per day."

Revenue code 250 does not require HCPCS coding. However, drugs that can be self-administered are not covered by Medicare.

HCPCS includes CPT-4 codes. Report HCPCS codes in FL44, "HCPCS/Rates." HCPCS code reporting is effective for claims with dates of service on or after April 1, 2000.

The professional services listed below are separately covered and are paid as the professional services of physicians and other practitioners. These professional services are unbundled and these practitioners (other than physician assistants (PAs)) bill the Medicare Part B carrier directly for the professional services furnished to your partial hospitalization patients. You can also serve as a billing agent for these professionals by billing the Part B carrier on their behalf for their professional services. The professional services of a PA can be billed to the carrier only by the PAs employer. The following professional services are unbundled and not paid as partial hospitalization services:

• Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;
• PA services, as defined in §1861(s)(2)(K)(i) of the Act;
• Nurse practitioner and clinical nurse specialist services, as defined in §1861(s)(2)(K)(ii) of the Act; and
• Clinical psychologist services, as defined in §1861(ii) of the Act.

The services of other practitioners, (including clinical social workers and occupational therapists) are bundled when furnished to your patients and these nonphysician practitioner services can be billed to the intermediary.

Physician Assistant services can only be billed by the actual employer of the PA. The employer of a PA may be such entities or individuals as a physician, medical group, professional corporation, hospital, SNF, or nursing facility. For example, if a physician is the employer of the PA and the PA renders services in your facility, the physician and not you is responsible for billing the carrier on Form HCFA?1500 for the services of the PA.

D.    Outpatient Mental Health Treatment Limitation - The limitation may apply to services to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CNSs, and PAs to partial hospitalizaiton patients. However, the outpatient mental health treatment limitation does not apply to such mental health treatment services billed to the intermediary as partial hospitalization services.

E.    Reporting of Service Units - Visits should no longer be reported as units. Instead, report in Form Locator (FL) 46, "Service Units," the number of times the service or procedure as defined by the HCPCS code was performed when billing for the partial hospitalization services identified by revenue codes in subsection C.

EXAMPLE: A beneficiary received psychological testing (HCPCS code 96100 which is defined in one hour intervals) for a total of 3 hours during one day. Report revenue code 918 in FL 42, HCPCS code 96100 in FL 44, and "three" units in FL 46.

When reporting service units for HCPCS codes where the definition of the procedure does not include any reference to time (either minutes, hours or days), do not bill for sessions of less than 45 minutes.

Maryland Medicare will return to you claims that contain more than one unit for HCPCS codes G0129, Q0082 and G0172 or that do not contain service units for a given HCPCS code.

NOTE: Service units are not required to be reported for drugs and biologicals (Revenue Code 250).

F.    Line Item Date of Service Reporting - You are required to report line item dates of service per revenue code line for partial hospitalization claims that span two or more dates. This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the service was provided for every occurrence. Line item dates of service are reported in FL 45 "Service Date" (MMDDYY). See examples below of reporting line item dates of service. These examples are for group therapy services provided twice during a billing period.

For the UB-92 flat file, report as follows:

For the hard copy UB-92 (HCFA-1450), report as follows:

For the Medicare A 837 Health Care Claim version 3051 implementations 3A.01 and 1A.C1, report as follows:

LX*1~
SV2*915*HC:90849*80*UN*1~
DTP*472*D8*19990505~
LX*2~
SV2*915*HC:90849*160*UN*2~
DTP*472*D8*19990529~

Maryland Medicare will return to you claims that span two or more dates if a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside the statement covers period. Line item date of service reporting is effective for claims with dates of service on or after April 1, 2000.

G.    Payment - Section 1833(a)(2)(B) of the Act provides the statutory authority governing payment for partial hospitalization services provided by you. Payment will be made on a reasonable cost basis until July 1, 2000. The Part B deductible and coinsurance apply. Beginning with services provided on or after July 1, 2000, payment will be made on a per diem basis under the hospital outpatient prospective payment system for partial hospitalization services. You must continue to maintain documentation to support medical necessity of each service provided, including the beginning and ending time.

These instructions are effective for claims with dates of service on or after April 1, 2000. Implementation date is April 1, 2000.

Please call the Provider Relations department at 410-561-0541, if you have any questions regarding this bulletin.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE AT NO-COST FROM OUR WEBSITE AT www.marylandmedicare.com

(Source: HCFA Pub. 9, §414;Transmittal # 7 and HCFA Pub. 13-3MIM, Transmittal #1784)