Q&A: How do we meet partial hospitalization program requirements?

Q: We have some patients in our partial hospitalization program who need intensive care, but don’t always meet the minimum number of hours. We have a weekly meeting with our providers to ensure that the plan of care meets the CMS requirements, and if not, what other options are available. One of our providers insists that some patients need the intensive care, but “just not that much time” – these patients are getting what they need in a less amount of time and there is no need to require them to come for additional services just to meet the 20-hour requirement.

A: Partial hospitalization programs (PHP) are designated to be “in lieu of inpatient hospitalization” for mental health conditions. The regulations are very specific (42 CFR 410.43(c)(1)) that these programs are a replacement for inpatient care and therefore, require a substantial amount of time involvement. CMS states that “PHPs are intended for patients who require a minimum of 20 hours per week of therapeutic services as evidenced in their plan of care.” The regulations also require that these services are furnished under a physician certification and plan of care (42 CFR 424.24(e)).

CMS stated on p. 482 in the 2017 OPPS final rule that it was becoming apparent from claims data that patients were not receiving the required minimum number of hours based on the services that were reported. There is a lengthy discussion in the final rule about the impact that this had on the OPPS payments. CMS also noted that changes would have to be made to ensure that the regulation requirements were being met. This was still open for comment in the final rule.

CMS issued Transmittal 1883 on April 28, noting that the first step being taken is that CMS will notify providers via the remittance advice that the patient did not receive the minimum 20 hours per week of therapeutic services. These messages will be implemented on October 1, 2017, for dates of service starting that day, and are intended “to increase provider awareness of the regulations at 42 CFR 410.43(c)(1) and 42 CFR 410.43(a)(3).” This will begin with an alert and a change that Edit 95 will now be applied at the line-item level and no longer at the claim level. Payment will be provided and the alert will be issued on the remittance advice. While no date is provided, CMS notes that in the future, the flag will be changed and the service will no longer be paid if it does not meet the 20-hour minimum requirement.

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.

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