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.