Local Coverage Determination L33626: Psychiatric Partial Hospitalization Programs

A psychiatric partial hospitalization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care, designed to provide patients with profound or disabling mental health conditions an individualized, coordinated, intensive, comprehensive and multidisciplinary treatment program not provided in a regular outpatient setting. Partial hospitalization services are furnished by a hospital or CMHC to patients with acute mental illness in order to avoid inpatient care through this type of ambulatory care.

Patients admitted to a partial hospitalization program generally must have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR™) published by the American Psychiatric Association (2000.

National Government Services has published the PHP LCD L33626 and it has been in effect since 10/1/2015. The associated Billing and Coding: Psychiatric Partial Hospitalization Programs article, A56850 has been in effect since 11/14/2019. Part B providers submitting PHP claims to Medicare for medically necessary PHP services should review the detailed guidelines as stated in the Billing and Coding Article, as prepay editing will take effect on 5/13/2021. Under the heading of Coding Information, there is an extensive list of ICD-10 Codes that Support Medical Necessity. Providers should assure that they have evaluated this list prior to submitting the PHP service to Medicare.

It should be noted that the correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Posted 3/26/2021