Local Coverage Determination L33626: Psychiatric Partial Hospitalization Programs – Reminder

What is Psychiatric Partial Hospitalization?

• • A distinct and organized intensive psychiatric outpatient treatment
  • Less than 24 hours of daily care provided
  • Designed for patients with profound or disabling mental health conditions
  • Provides an individualized, coordinated, intensive, comprehensive and multidisciplinary treatment program not provided in a regular outpatient setting
  • Furnished by a hospital or CMHC
  • Avoids inpatient care through ambulatory care

Patients admitted to a PHP 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).

Reminder

The published Psychiatric Partial Hospitalization Programs (PPHP) LCD L33626 containing ICD-10-CM codes has been in effect since 10/1/2015. PHP providers submitting claims to Medicare for medically necessary PHP services should review the detailed guidelines as stated in the LCD. Under the heading of Coding Information there is an extensive list of ICD-10 Codes that support medical necessity. Providers should ensure 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 2/11/2019