2.1 Per
Diem Payment For PHPs Or IOPs
PHPs 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.
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)(vii) 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.
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 calendar 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 (e.g., 60 minutes individual, 90 minutes
family) 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 or 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 (e.g., to treat
a broken leg, appendicitis, heart attack) 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, 2016
2.6.1 For 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 calendar
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.
2.6.2 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 for
reimbursement in hospital-based PHPs.
For dates of service prior
to October 3, 2016, cost-sharing for PHP services is made on an
inpatient basis. For dates of service on or after October 3, 2016,
outpatient cost-sharing is applied to PHP and IOP services. See
Chapter 2, Addendum A.