Partial Hospitalization Program (PHP) billing uses revenue code 0912 (facility) combined with HCPCS S0201 (per diem, per patient, per day) or H0035 (per diem partial hospitalization). PHP requires a minimum 20 hours per week of structured programming including individual therapy, group therapy, psychiatric medication management, and skill-building groups. Prior authorization is mandatory before enrollment. Medicare requires concurrent review every 5-7 days to verify ongoing medical necessity. Discharge planning begins at admission with a target length of stay (typically 2-8 weeks). PHP operates Monday-Friday, 6-8 hours daily.
Bill daily per diem rates, not hourly. Submit one claim per patient per day with revenue code 0912 + HCPCS S0201 or H0035. The per diem covers all services delivered that day (psychiatry, individual therapy, groups, medication management). Do not separately bill therapy codes (90837, 90853) for sessions that occur within the PHP program. Document the diagnosis using the primary mental health ICD-10 code (e.g., major depression F32.9, bipolar disorder F31.13). PHP is covered under Medicare Part B for mental health diagnoses. Private insurance coverage varies. Verify your patient's plan before the first day.
Prior auth is required before PHP enrollment by 99% of payers. Submit the patient's primary diagnosis, current psychiatric symptoms, reason for hospitalization vs. outpatient (e.g., suicidal ideation, severe depression with functional impairment), proposed treatment plan, and expected discharge date. Medicare approves PHP for acute psychiatric diagnoses lasting 2-8 weeks. Most commercial payers auto-approve 2 weeks; longer stays require clinical justification. Some plans limit PHP to once per year. Concurrent review is mandatory every 5-7 days; missing a review triggers automatic denial. Payers track admission and discharge dates—back-to-back PHP enrollments raise red flags.
Do not bill therapy codes or E/M codes separately when the patient is enrolled in PHP. All services are included in the per diem. If a patient attends PHP and also has an outside psychiatrist who prescribes medication but does not participate in the PHP program, the outside psychiatrist bills E/M separately (with appropriate documentation that they are not part of the PHP team). Residential treatment center (RTC) and PHP are mutually exclusive—do not bill both simultaneously.
Maintain daily attendance records showing the hours the patient participated. Document each group attended, individual therapy completed, and psychiatric services rendered. Record baseline symptom severity (PHQ-9 for depression, PANSS for psychosis, etc.) and weekly progress notes showing improvement toward discharge goals. Include the treatment plan: specific diagnoses, psychiatric medications, therapy focus areas, and skills targets. Before discharge, document the patient's progress, response to treatment, and discharge disposition (return to outpatient, intensive outpatient, day treatment, or inpatient hospitalization). Document each concurrent review and payer approval.
Most payers require 20 hours minimum. Some commercial plans allow 15-20 hours. Check your patient's plan. If the patient cannot commit to 20 hours, use Intensive Outpatient Program (IOP), which typically requires 9-12 hours per week, instead. IOP uses different billing codes (H0034, H0032).
Submit a concurrent review update 2-3 days before the authorized days expire. Provide new progress notes showing clinical improvement, ongoing psychiatric instability, or reasons for continued hospitalization. Most payers approve extensions for acute diagnoses. Delays in submitting extensions result in claim denials. Proactive communication is critical.
Major depression, bipolar disorder, psychosis, suicidal ideation with high risk, severe anxiety, acute PTSD, substance use with withdrawal risk, and acute personality disorder decompensation qualify. Adjustment disorder or mild depression typically does not. Use diagnoses that indicate acute psychiatric crisis requiring intensive monitoring, not routine outpatient care.
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