Billing PHP claims on a weekly basis

Q: We operate a partial hospitalization program (PHP) and just heard from our billing office that there are new requirements for submitting claims. They want us to close out accounts weekly in order for them to bill them. We have done 30-day accounts prior to this and don’t see why they want to change things. Is there a certain timeframe required for billing these services? This is a huge inconvenience to make this work for the business office.

A: Your business office is not trying to make things difficult for you. CMS has changed the billing requirement for PHP. Beginning July 1, CMS is instituting new billing edits to ensure that the benefit requirements are met for coverage and reimbursement of the services.

Section 1861 (ff) of the Social Security Act describes the items and services that must be provided. The purpose of a PHP is to provide intensive outpatient psychiatric care in a structured short-term hospital program for patients who have a situation that severely interferes with multiple areas of their daily life and their ability to function in those areas of life.

These patients must be under the care of a physician who has certified the need for PHP services. Part of this certification is the requirement that a minimum of 20 hours per week of therapeutic services is required. These patients are those who require comprehensive and structured treatment, including medical supervision and coordination that is provided under an individualized plan of care. Social, recreational, or diversionary activities are not included in the PHP scope or plan of care.

CMS has noticed in claims data and documentation that the 20-hour-per-week minimum is not being met. To enforce this requirement, CMS is instituting new edits into the I/OCE software in the July release.

In order to implement the enforcement edits, weekly billing will be required. CMS provided advance notice in Transmittal SE1607 and the requirement has been implemented with claims submitted on or after July 1, 2016. Note that this is not based on date of service but date of claim submission.

If the requirements are not met, the claims will lead to edits in the claims processing system:

• If the claim span is equal to or more than 4 days with an insufficient number of hours reported (Edit 95)
• An interim claim must span more than 4 days (Edit 96)
• PHP services must be billed on a weekly basis (Edit 97)

Beginning with the July implementation, Edit 95 will return the claim to the provider for review and correction (if appropriate.) Beginning October 1, CMS plans to change the parameters of Edit 95 to deny the claim.

In summary, CMS is changing the billing cycle for PHP services to be on a weekly basis in order to insure that the required 20-hour minimum is being provided to patients in order to insure that they meet the benefit requirements. If not, the claim will be returned to the provided for the first quarter of the edit implementation; after that time, the claim will deny if the requirements are not met.

See here for more information.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.