Reader Question: Partial Hospitalization

Question: Weve been having problems with some of our partial-hospitalization services. These should be paid under APCs. What are we missing?

Kentucky Subscriber

Answer: You might be missing the necessary diagnoses for partial-hospitalization services. Your claim must include a mental-health diagnosis and indicate the HCPCS and revenue codes that best describe the services furnished for each day of service. You will need at least three HCPCS codes for partial hospitalization on each date of service. One of these HCPCS codes must be a psychotherapy code.

A lot depends on which edits you are receiving. For example, edit 29 is for non-mental-health diagnosis; edit 30 is for insufficient services on day of partial-hospitalization (no psychotherapy code). A list of covered partial hospitalization services is in section 1861(ff) of the Social Security Act as well as HCFAs APCs Training Manual (available at http://www.hcfa.gov). These services include occupational therapy requiring the skills of a qualified occupational therapist; drugs and biologicals that cannot be self-administered, which are furnished for therapeutic purposes; and family counseling when the primary purpose is treatment of the individuals condition.

In the OPPS Final Rule, HCFA did clarify that some of the covered services, such as patient education and training and activity therapy, may be provided by unlicensed but qualified staff specifically trained to work with the mentally ill.

The table below includes some of the revenue and HCPCS codes that HCFA will be looking for to appropriately validate the partial-hospitalization service:

Revenue Code: CPT Code(s)

43x: Occupational therapy G0129 (occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day)

910: Psychiatric general services 90801, 90802, 90875, 90876 or 90899

914: Individual psychotherapy 90816, 90818, 90821, 90823, 90826 or 90828

915: Group psychotherapy 90849, 90853, 90857

916: Family psychotherapy 90846, 90847, 90849

918: Psychiatric testing 96100, 96115, 96117


- Published on 2001-05-01