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.