2.1 Per Diem
Payment For
PHPs Or IOPsPHPs authorized
and provided under
32 CFR 199.4(b)(10) and provided by psychiatric
PHPs authorized under
32 CFR 199.6(b)(4)(xii) are
reimbursed on the basis of prospectively determined, all-inclusive
per diem rates. The per diem payment amount must be accepted as
payment in full for all PHP services provided.
Effective
on May 1, 2009 (implementation of OPPS), hospital-based PHP services
are reimbursed under the hospital OPPS as described in
Chapter 13, Section 2, paragraph 3.7.
Effective
for dates of service on or after October 3, 2016, per diem payment
for IOP services provided by PHPs or IOPs authorized under 32 CFR 199.4(b)(9) and (b)(10), and provided by PHPs and IOPs authorized
under 32 CFR 199.6(b)(4)(xii) and (b)(4)(xviii) are reimbursed on the basis
of prospectively-determined, all-inclusive per diem rates. The per
diem payment amount must be accepted as payment in full for all
PHP or IOP services provided. The following services and supplies
are included in the per diem rate approved for authorized PHPs and
IOPs and are not covered even if separately billed by an individual provider.
2.1.1 Board.
Includes use of the partial hospital facilities such as food service,
supervised therapeutically constructed recreational and social activities,
etc.
2.1.2 Patient assessment. Includes the assessment
of each individual accepted by the facility, and must, at a minimum,
consist of a physical examination; psychiatric examination; psychological assessment;
assessment of physiological, biological and cognitive processes;
developmental assessment; family history and assessment; social
history and assessment; educational or vocational history and assessment;
environmental assessment; and recreational/activities assessment. Assessments
conducted within 30 days prior to admission to a partial program
may be used if approved and deemed adequate to permit treatment
planning by the PHP.
2.1.3 Psychological testing and
assessment.
2.1.4 Treatment services. All services including
routine nursing services, group therapy, supplies, equipment and
space necessary to fulfill the requirements of each patient’s individualized
diagnosis and treatment plan (with the exception of the psychotherapy
as indicated in
paragraph 2.2.1). All mental health services
must be provided by an authorized individual professional provider
of mental health services. [Exception: PHPs
or IOPs that
employ individuals with master’s or doctoral level degrees in a
mental health discipline who do not meet the licensure, certification
and experience requirements for a qualified mental health provider
but are actively working toward licensure or certification, may provide
services within the all-inclusive per diem rate but the individual
must work under the clinical supervision of a fully qualified mental
health provider employed by the PHP
or IOP.]
2.1.5 Ancillary
therapies. Includes art, music, dance, occupational, and other such
therapies.
2.1.6 Overhead and any other services for which the
customary practice among similar providers is included as part of
the institutional charges.
2.2 Services Which May Be Billed
Separately
The following services are not
considered as included within the per diem payment amount and may
be separately billed when provided by an authorized individual professional
provider:
2.2.1
Psychotherapy
Sessions
Professional services provided by an authorized
individual professional provider (who is not employed by or under
contract with the PHP or IOP) for purposes of providing clinical
patient care to a patient in the PHP or IOP may be cost-shared when
billed by the individual professional provider. Any obligation of
a professional provider to provide services through employment or
contract in a facility or distinct program of a facility would preclude
that professional provider from receiving separate TRICARE reimbursement
on a fee-for-service basis to the extent that those services are covered
by the employment or contract arrangement. Psychotherapy services
provided outside of the employment/contract arrangement can be reimbursed
separately from the PHPs or IOPs per diem.
Note: For
dates of service prior to October 3, 2016, professional
mental health benefits are limited to a maximum of one session (60
minutes individual, 90 minutes family, etc.) per authorized treatment day
not to exceed five sessions in any calendar week in any combination
of individual and family therapy. For dates of service prior to
October 3, 2016, five sessions per week is an absolute limit, and additional
sessions are not covered.
Note: Group therapy
is strictly included in the per diem and cannot be paid separately
even if billed by an individual professional provider.
2.2.2 Primary/Attending
Provider
When a patient is approved for admission to
a PHP or IOP, the primary or attending provider
(if not contracted or employed by the partial program) may provide
psychotherapy only when the care is part of the treatment environment
which is the therapeutic partial program. That is why the patient
is there--because that level of care and that program have been
determined as medically necessary. The therapy must be adapted toward
the events and interactions outlined in the treatment plan and be
part of the overall partial treatment plan. Involvement as the primary
or attending is allowed and covered only if he is part of the coherent
and specific plan of treatment arranged in the partial setting.
The treatment program must be under the general direction of the
psychiatrist employed by the program to ensure medication and physical
needs of the patients are met and the therapist must be part of
the treatment team and treatment plan. An attending provider must
come to the treatment plan meetings and his/her care must be coordinated
with the treatment team and as part of the treatment plan. Care
given independent of this is not covered.
2.2.3 Non-
Mental
Health
Related
Medical
Services
Those services not normally included in the
evaluation and assessment of a partial hospitalization patient and
not related to care in the PHP or IOP.
These medical services are those services medically necessary to
treat a broken leg, appendicitis, heart attack, etc., which may necessitate
emergency transport to a nearby hospital for medical attention.
Ambulance services may be cost-shared when billed for by an authorized
provider if determined medically necessary for emergency transport.
2.3
Per Diem Rate
2.3.1 For any full-day PHP (minimum of six hours),
the maximum per diem payment amount is 40% of the average inpatient
per diem amount per case paid to both high and low volume psychiatric hospitals
and units established under the mental health per diem reimbursement
system. The rates shall be updated to the current year using the
same factors as used under the TRICARE mental health per diem reimbursement
system.
2.3.2 A PHP of
less than six hours (with a minimum of three hours) will be paid
a per diem rate of 75% of the rate for full-day PHP.
2.3.3 For
dates of services on or after October 3, 2016, IOP services, lasting
less than six hours, with a minimum of two hours, shall be reimbursed
a per diem rate of 75% of the rate for full-day PHP.
Note: PHPs
that provide services that are less than six hours, with a minimum
of two hours, are reimbursed in accordance with the provisions of paragraph 2.3.3.
2.4 Other Requirements
No payment is due for leave days, for days
in which treatment is not provided, for days in which the patient
does not keep an appointment, or for days in which the duration
of the program services was less than three hours.
2.6
IOPs
Prior
To October 3, 2016For
dates of service prior to October 3, 2016, PHPs may
provide services they call “Intensive Outpatient Program”, or IOP.
PHPs may provide partial hospitalization services, also referred
to as IOP, provided less than five days per week, but at least three
hours per day but less than six hours per day. Freestanding PHPs
providing IOP services may submit reimbursement for Healthcare Common Procedure
Coding System (HCPCS) codes S9480 or H0015 to represent these services;
the contractor shall reimburse the provider the half-day PHP rate
(i.e., three to five hours), in accordance with this section. See
the TRICARE Policy Manual (TPM),
Chapter 7, Sections 3.4 and
3.5; and
Chapter 13, Section 2, paragraph 3.7.3.2 for
reimbursement in hospital-based PHPs.