When using comparisons to review programs, administrators should not penalize individual programs that have developed a plan to improve the program. However, they should be a separate, identifiable unit and represent a continuum of therapeutic modalities that are evidence based for children and adolescents. Programs can provide daily symptom management, while at the same time, necessary case management services are engaged to foster the highest level of functioning possible. These meetings are critical to achieve continuity of client care, address the identified needs of the therapeutic community, assure appropriate utilization of services, and maintain necessary operational efficiencies. Bill Type 13X is billed with Condition Code 41 (Partial Hospitalization) and the HCPCS code is not We encourage a shift in the oversight focus from document analysis to a concern for outcomes and the overall client experience. CMS reviews claims and provides an opportunity to recommend changes to the PHP and IOP guidelines annually. Importantly, States vary in the scopes of work for many disciplines. Each State has licensing agencies that regulate the licensing of professional staff. This will require a program to review the criteria and make a decision that is in the best interest of the program and the individuals being served. Telehealth services in PHP and IOP are demonstrating to be useful as an additional service modality. Program Criteria. Medicare reimburses for a given number of specific services per day. Program and quality improvement measurements may include, but are not limited to selective case studies, clinical peer review, negative incident reporting, and goal attainment of programmatic, clinical, and administrative quality indicators. This program typically lasts about 10 business days. There arethreeaccreditation organizations used by behavioral health facilities: A key player in detailing programming and documentation will be the organizations that pay for services. All programs pursue the goals of stabilizing clinical conditions, reducing symptoms and impairments, averting or reducing inpatient hospitalization stays, and providing medically necessary treatment for individuals who cannot be effectively treated in a less intensive level of care. Subspecialty groups focus on the specifics of given targeted populations such as trauma, substance use, eating disorders, OCD, or cardiac/depressive conditions. The documentation of medical supervision and certificate of need must be completed upon entry to the program and updated periodically based on individual need, program policy, and payer expectations. In some cases, local and regional expectations and standards regarding documentation requirements may vary and programs are reminded that documentation requirements may need to change based on different state requirements.. Provide at least 4 days, but not more than 5 out of 7 calendar days, of partial hospitalization program services Ensure a minimum of 20 service components and a minimum of 20 hours in a 7 calendar-day period Provide a minimum of 5 to 6 hours of services per day for an adult aged 18 years or older Programs must also maintain strong linkages with emergency departments, inpatient psychiatric units, and chemical dependency programs in order to facilitate both admission and discharges. It may also incorporate access to care, length of stay, medical necessity criteria, or demographic data to evaluate treatment practices, treatment environment, the distribution of staff assignments, or the potential need for new services. Mol, J.M. It can also be used to track benchmarking data such as dropouts, re-hospitalizations, absenteeism, and related metrics. A comprehensive program improvement plan should include an internal review process to assess the appropriate use of program services. Patients admitted to a partial hospitalization program must be under the care of a physician who is knowledgeable about the patient and certifies the need for partial hospitalization. See DSM-5 for details on these diagnostic categories, and the levels of severity. If suicide risk is present in the participant, take action immediately, including staying online with them until help and safety has been secured. To manage medical and behavioral emergencies, policies should be developed to expedite admission for inpatient care if required and allow for timely pharmacological intervention. Some flexibility in programming should always be considered given individual circumstances, Is uninterested or unable due to their illness to engage in identifying goals for treatment and/or declines participation as mutually agreed upon in the treatment plan, Is imminently at risk of suicide or homicide and lacks sufficient impulse/behavioral control and/or minimum necessary social support to maintain safety that requires hospitalization, Has cognitive dysfunction that precludes integration of newly learned material, skill enhancement, or behavioral change, Has a condition such as social phobia, severe mania, anxiety, or paranoid states in which the individual may become more symptomatic in a predominantly group treatment setting, Has primarily social, custodial, recreational, or respite needs. These standards include guidelines and consensus statements produced by professional specialty . Partial Hospitalization Program Policy Number: SC14P0034A3 Effective Date: May 1, 2018 . When developing program schedule, consider your population and how you will structure school (i.e. CMS contracts with intermediaries to manage the requirements for PHP and IOP services. There are three principal forms of linkage: FIRST, internal linkages between programs, departments, or practitioners within the same organization. The physician provides supervision of the clinical needs of the individuals enrolled in the program. Ongoing clinical responsibility must continue and be clarified while individuals are awaiting follow up care. In view of PHPs and IOPs positions in the continuum of behavioral health services, programs must maintain liaison relationships with multiple behavioral health providers, physical health care providers, and others. (Section 1-101.1 of the Code) "Accreditation." A process establishing that a program complies with nationally-recognized standards of . Adult Brain Injury. If medications are changed during treatment, the types and dosages, clinician responsibility, and timing should be clearly documented with the rationale for the medication changes. Recently in behavioral health, a few payers are developing protocols that are not in line with Medicare guidelines, which again can create challenges in programming and billing. Coordinated care services aims to keep a key person/entity involved in the entire treatment process as a proxy for a person who may struggle with the complexities of the health system. Kiser, J.L., Trachta, A.M., Bragman, J.I., Curley-Spadaro, K., Cooke, J.D., Ramsland, S.E., and Fitzhugh, K.E. The fifth edition was completed in 2012. In a recent NABH Annual Survey, more than half (56.8%) of all NABH members responding offered psychiatric partial hospitalization services for their communities, and more than a third (35%) offered partial hospital addiction services.Throughout the years, these NABH members have been a stable group of providers . Number of hours of structured treatment provided per day, Individual assessment/therapy/intervention time needed, Management of potential for self-harm or other emergencies, Need for specialized nursing or case management services. 343-351, 2013. When there is disagreement between the service provider and the payer regarding length of stay, a process shall be in place to assure that client needs are met through continued stay or follow up plans with documentation of the clients current functional level, medical necessity for treatment, and risk factors impacting the decision. Final determination of changes is usually published in November of each year. Scheifler, P.L. The interactive telecommunication technology included audio and video. PHP and IOP needs may or may not be adequately addressed due to unique workflow documentation, and billing challenges. Regulatory agencies will often assess the use of outcome measures as a core part of a quality improvement plan for programming. Services may include group, individual, couples, family therapy and medication management for symptom management. Additionally, liaison with outpatient services of less intensity is necessary in order to facilitate admissions and continuity of care, as well as to arrange for adequate continued treatment when partial hospitalization services are no longer necessary. 2013) 10, 2013. Texas Administrative Code Texas Administrative Code TITLE 28 INSURANCE PART 1 TEXAS DEPARTMENT OF INSURANCE CHAPTER 3 LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES SUBCHAPTER HH STANDARDS FOR REASONABLE COST CONTROL AND UTILIZATION REVIEW FOR CHEMICAL DEPENDENCY TREATMENT CENTERS Rules This variation may offer unique program performance improvement options. Client rights guidelines includes: Rights and Responsibilities, Compliant/Grievance process, confidentiality, access to emergency services if in crisis and must be signed . Portsmouth, Virginia. Irvin D. Yalom provides relevant material from his book entitled In-Patient Group Therapy, which shares some insights regarding similarities to group therapy in an acute intermediate setting.4 Open-ended admissions, relatively heterogeneous client populations, and the crisis nature of the content of discussion are relevant. Partial Hospitalization Programs (PHP) - Partial hospital implies a daily psychosocial milieu treatment of generally four or more hours duration a day with group therapy, psycho-educational training, and other types of appropriate therapy as the primary treatment modalities. August 23, 2017 - CMS revoked Medicare reimbursement changes to its medical billing requirements and process for partial hospitalization services, according to a recent Medicare Learning Network announcement. Partial hospitalization has long been a level of care offered by NABH members. Level 2.1 intensive outpatient programs provide 9-19 hours of weekly The role of physicians is typically not included in staff to client ratio. The best way to find out about Medicaid guidelines is the first contact the State office responsible for guidelines and ask for guidance. The American Society of Addiction Medicines (ASAM) Patient Placement Criteria (ASAM PPC-2R) (previously mentioned) is considered a best practice for assessing and determining level of care placement for individuals with substance use disorders.6, Psychoactive substance history & detoxification status, Emotional/behavioral/cognitive functioning. Medical oversight is necessary with additional daily, hourly structure to contain and monitor client movement. These organizations usually conduct surveys of facilities on a regular basis and provide detailed reports on the areas where programs excelandwhere programsneed improvement. The program can also function as a first step to achieve a measure of sobriety, and to assist in determining a differential diagnosis once the individual has begun the recovery process. For each person seen through telehealth, the staff providing a treatment service must have the following readily available: Any individual offered telehealth services must consent to telehealth services and should acknowledge consent before the first session of telehealth service: [Provide the statements through email or display on the screen during an intake or first session]. It is important to indicate the timing of data collection when the record includes updates on previously obtained material. A recovery model that focuses on increased quality of life is essential to give the older adult investment and purpose in treatment. Institute of Medicine of the National Academies. On the other hand, integrated occupational therapy programs complement other services and teach valuable skills within an evidence -based model that contributes significantly to positive clinical outcomes. Clinicians should utilize language in documentation that notes telehealth use. American Society of Addiction Medicine (ASAM) (April 2001). The Institute of Medicine (IOM) published a 2011 report entitled Health IT and Patient Safety.5 This report suggests that a successful EMR is designed to enhance workflow without increasing workloads, allow for an easy transfer of information to and from other providers, and (hopefully) address the perils of unanticipated downtime. Cognitive and physical impairments may make day-long treatment services demanding for some individuals. Only use approved platforms for any telehealth contacts . A mixed group means mixed level of attention to participants. The assessment tools in the record must include all relevant information and have the capacity to go beyond documentation of the presence or absence of specific criteria through checklists or drop-down boxes. PHPs have their own set of rules and guidelines that are not discussed here ( click here to read more about PHPs). Along with the advent of the medical care home, the number of mental health professionals providing screening, consultation, limited counseling, and other behavioral health services on site in primary care settings has been growing rapidly in recent years. Connellan, K., Bartholomaeus, C., Due, C., & Riggs, D. A systematic review of research on psychiatric Mother-Baby units. AABH has an ongoing national benchmarking project that enables individual programs to record data on multiple indices and compares them with similar programs across the country. Second Edition. Association for Ambulatory Behavioral Healthcare, 2015. An effective monitoring strategy must be developed to assure accuracy and prevent errors in data submission and transmittal. A given programs metrics may vary significantly based on the diagnostic characteristics of those who attend program and may help direct changes to programming to better meet the needs of the population in program. Additional elements include opinions related to the programs use of effective treatment methods, relevance of therapeutic subject matter, cultural sensitivity, teamwork, and the overall quality of care. Treatment should include collaboration with school, involved community agencies and established providers. guidelines including the Level of Care Utilization System (LOCUS), hildren's Level of are . We have prepared this article to provide general guidelines for insurance billing for PHP. Treatment Guidelines Care Based Guidelines 1. teacher on staff vs. Substance Abuse and Mental Health Services Administration News Release. Common problems related to symptoms, life situation, and skill deficits lead to group topics. In addition, programs need to acknowledge that not all individuals have the appropriate devices, the WIFI access and the privacy to engage in the multiple groups per day format that we must maintain. Dads can also struggle with paternal depression and the mental health of the whole family is key to successful outcomes. Medical Assistance (where applicable) reimburses for hours of service in a given day, payment is on a per session basis for most insurance companies or specific individualized service for Medicare or Medical Assistance, Severity of dysfunction or behavioral symptoms, criteria for admission require more acute individual dysfunction, severity of symptoms, and potential for risk of harm to self or others, criteria for admission require moderate individual dysfunction, severity of symptoms, and potential for risk of harm to self or others, Hours and variety of intensive services per week, services offered at least 5 days per week with an average of 6 hours of treatment per day, people usually attend between 6 and 12 hours of treatment per week, specific State, Joint Commission, and other regulations, regulations are generally included within outpatient regulations, except for Medicare, staffing requirements are more specific regarding staff-client ratio with most clinical staff ratios are less than 1:12, Less regulation regarding size of caseload but caseloads tend to be larger than PHP, tend to provide more sessions over a longer period of time, Intensity of physician and supervisory oversight, require a higher demand of physician oversight that often includes coverage and/or supervision for all hours when clients are present. Benchmarking, whether internal or compared to peers, provides an overview of how elements of a program are performing. Oregon Administrative Rules. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically If an individual does not meet any of the above criteria, they may be appropriate for an intensive outpatient program. While there is significant financial and clinical impetus to provide these services in an integrated manner, state licensing dictates the extent to which programs may be integrated. The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Partial Hospitalization Programs L37633. All programs should consult with compliance officers in their organization to determine if there are specific staff-to-client ratios included within contracts. When acceptable to given payers or state reviewers, a comprehensive user-friendly synopsis of a persons progress through treatment may be provided. clinical judgment consistent with the standards of good medical practice will be used to . Individuals with co-occurring disorders tend to relapse frequently, placing them at greater jeopardy of a marginalized social existence. In some cases, a specialized IOP may be recommended as follow-up for specific conditions; Some individuals display increased symptoms of a previously diagnosed behavioral disorder and exhibit a progressive or sudden decline in functioning compared to baseline. Given these factors, staff-to-client ratios tend to vary and are addressed by each program according to need and staffing requirements. This table is available to members HERE. A hospital is a licensed facility that offers services more intensive than those required for room, board, personal services and general nursing care, and offers facilities and beds for use beyond 24 hours by individuals requiring medical, surgical, psychiatric, testing, diagnosis, treatment, or care for illness, injury, deformity, infirmity, abnormality, disease, or pregnancy. 7. Important to have prescribers with expertise in prescribing during pregnancy and lactation. Fifth Edition. The main objective is to receive feedback addressing the degree to which the program met the individuals needs and assisted in achieving their goals. Movement needs to be monitored hourly, determining how much movement or exercise is medically safe for each clients stability. In some cases, removal from a given residence or placement in a residence or residential treatment setting may be a precondition for treatment. The benchmark when no other exists can be a designated baseline of a measure within the program. Each program is encouraged to identify other programs that are relevant to their individual target populations particularly if there are demographic or secondary diagnostic changes. Recovery oriented service evaluations may also be helpful for programs. To assist in establishing a sense of program identity and community, the schedule should have a flexible yet coordinated array of therapeutic services indicating the days and times that specific services are scheduled. CNA (Certified Nurse Aide) Registry. Often the program is the first treatment setting for persons experiencing an acute exacerbation of symptoms. Payment will not be made for compensable peer support Second Edition. This document addresses the presenting problem, psychiatric symptoms, mental status, physical status, diagnosis, rationale for care, and treatment focus for the person while in treatment. Staff members assume responsibility for and control of the individuals safety due to the individuals severe, disabling symptoms. This final consideration is increasingly important in the world of accountable care. Association for Ambulatory Behavioral Healthcare, 1996. Accreditation of a program provides the community with increased confidence that a program meets minimum standards for safety and quality for the people the program serves. Although an individual may have several pressing needs, those that are of so severe they require the intensity of services of an intermediate level of care should be the top priority of treatment. Generally, the receiving program should have access to all aspects of the treatment in the previous program within the continuum, and accurately identify the source of information gathered while minimizing the difficulties for an individual to resume treatment. Portsmouth, Virginia. Consumers should also be informed as to where to direct additional feedback or complaints, such as quality management departments, local, state, and federal authorities, etc. As previously mentioned, individuals who have diagnoses for both mental health and substance use disorders of which only one is currently active, may be treated in a co-occurring (dual diagnosis) treatment setting, or in either an addictions or psychiatric treatment setting (depending upon which problem is currently active). They provide therapy and education in an intensive group environment that cannot be provided through either an outpatient individual therapy model or a crisis-oriented inpatient unit. The inclusion of two patient identifiers is helpful and often required on each document, such as a patient name and medical record number. AABH recognized that the significant population growth of older adults warranted the development of standards and guidelines for geriatric programs, last revised in 2007.20 The varied mental and physical capacities of seniors required individualized treatment, flexible treatment strategies, and unique aftercare challenges. These intermediaries are referred to as MACs (Medicare Administrative Contractor) and each can develop their own interpretation of the CMS guidelines in determining appropriateness for services, documentation requirements and billing requirements. Fourth Edition. Residential Treatment Position Statements . While these guidelinesmaynotbespecific enough foranyparticularprogram, they provide an overview of the core areas that need to be addressed in PHP and IOP. The necessity of and rationale for continued stay must also be documented in the medical record including the revised treatment plan when needed. 373-388, 2017. Archives of Womens Mental Health, 16. The average length of stay in short-term acute PHP may range from 5 to 30 days, while longer-term acute PHP may exceed 30 treatment days. While all three of these bodies can impact how a program provides services and determines appropriateness for care, state licensing agencies will have the regulations attached to laws in a State that must be followed. These programs are available at inpatient or residential treatment facilities. These four clinical profiles reflect individual scenarios that are appropriate for acute partial hospitalization program services. Generally speaking, a program's average length of stay should reflect the population treated and primary program function. 104 CMR 28. This provider is often determined by the complexity of the illness, medications, and overall medical or case management needs; Some individuals display a relatively high baseline functioning prior to the onset of a behavioral health condition yet require treatment in a partial hospitalization program to provide medication stabilization, insight, and self-management skills to reduce symptoms and risk to self-harm. A partial hospitalization program may be more appropriate in lieu of an intensive outpatient program if a number of these conditions are present: The following clinical presentations must be considered to admit a person to intermediate behavioral health services: Behavioral Health Symptoms: The individual exhibits serious and/or disabling symptoms related to an acute behavioral health condition or the exacerbation of symptoms from a severe and persistent mental disorder that has not improved or cannot be adequately addressed in a less intensive level of care. Limitations Noncovered-Reasonable and Necessary Denials CPT codes 90875 and 90876 Coding Information CPT/HCPCS Codes Expand All | Collapse All Group 1 (26 Codes) U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Longer-term programs develop increased group continuity due to the familiarity gained through more extended treatment yet work with more pronounced symptoms and decreased functional levels with lower baselines. Given a focus on healthcare integration, illness prevention, and the improvement of health outcomes, linkages between behavioral health and primary care providers is particularly important. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (January 2003). Organization should be clear for those who are less familiar with individualized medical recording formats and procedures like reviewers who conduct surveys through the observation of clinical records. While this section is not inclusive of all specific populations, these represent the populations in which there are a significant number of programs, enough to be establishing best practice. Programs providing primarily social, recreational, or diversionary activities are not considered partial hospitalization. Programs operate under the direction of a physician and a program leader. Programs should consider the focus of some of their programming on maternal fetal attachment with bonding groups like infant massage, playing with baby, etc.)12. A minimal ability and willingness to set goals to work toward the development of social support is often a requirement for participation. Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit. Retrieved July 20, 2018, from http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cooccurring/. They should provide face-to-face services with each client upon admission for an evaluation and thereafter as clinically indicated. Programs serving pregnant women or new mothers typically care for women with some type of Perinatal Mood and Anxiety Disorders (PMAD). l) Services provided to more than one beneficiary at a time, unless specifically allowed in the service definition. A complete medical record should include the following: The initial assessment addresses the individuals bio-psychosocial status and strengths including, but not limited to: Each assessment needs to include screenings for potential risks, needs, physical evaluations, or referrals. Primary care services are generally delivered during a regular office visit. The capacity to update and refine the system in a timely manner must be assured where administrative, clinical, regulatory, and performance improvement matters are concerned. The CARES Act of 2021 mandates that all providers of treatment make the full medical record, including behavioral health records, available to any individual who received services in that organization. However, any licensing conflicts and decision related to resolving the conflict should be reviewed by the compliance and legal departments or an organization. Provision of this method of service is appropriate when the persons served may be exposed to severe illness or attending in-person treatment may be impractical (e.g., transportation, distance, commute time, or no local expertise available to treat the impairment). Efforts to achieve best practices require analyses of critical data points, clinical outcomes, and treatment processes. 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