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A Medicare Partial
Hospitalization Program (PHP) is a comprehensive, structured program. A PHP
uses a multi-disciplinary team to provide comprehensive, coordinated
services within an individualized treatment plan to individuals diagnosed
with one or more psychiatric disorders. PHP requires admission and
certification of need by a physician (M.D./D.O.) trained in the diagnosis
and treatment of psychiatric illness.
These programs are designed to treat patients who exhibit severe or
disabling conditions related to an acute psychiatric/psychological
condition or an exacerbation of a severe and persistent mental disorder.
The psychiatric condition must require active treatment.
Partial Hospitalization programs are furnished by a hospital or community
mental health center (CMHC) as a distinct and organized intensive
ambulatory treatment.
At a minimum, the program should have available twenty hours (20 hrs.) of
scheduled programming extending over five (5) days per week.
The length of stay in a PHP is dependent upon the patient’s psychiatric
problems, clinical needs, types of treatment and response to treatment.
Many factors affect the outcome of treatment; among them are the nature of
the illness, the prior history, the goals of treatment and the patient’s
response. It is anticipated that a patient accepted into the PHP would be
promptly evaluated within 24 hours of admission and expediently treated, then
be maintained in an outpatient setting.
A partial hospitalization program differs from inpatient hospitalization
and outpatient management in day programs (i.e., adult day programs or
psychosocial programs), and periodic office visits for management of medication
and psychotherapy in:
- The intensity of the treatment programs
and frequency of participation by the patient; and
- The comprehensive structured program of
services provided that are specified in an individualized treatment
plan. The individualized treatment plan is formulated by a physician
and a multi-disciplinary team with the patient’s involvement. The
individualized treatment must be active.
Active Treatment refers to the ongoing provision of clinically
recognized therapeutic interventions that are goal-directed and based
on a documented treatment plan. Examples of active treatment include,
but are not limited to, pharmacotherapy, individual therapy, and group
therapy.
In order to be considered active treatment the following criteria must
be met:
- Treatment is directed toward the
alleviation of the impairment that precipitated entrance in the
program or which required continued level of intervention
- Treatment enhances the patient’s coping
abilities; and
- Treatment is individualized to address
the specific clinical needs of the patient
Active treatment does not include services to maintain generally
independent clients who are able to function with little supervision, or in
the absence of a continuous active treatment program.
A Medicare partial hospitalization program is an appropriate level of
active treatment intervention for individuals who:
- Are likely to benefit from a coordinated
program of services and require more than isolated sessions of
outpatient treatment. Partial hospitalization is the level of
intervention that falls between inpatient hospitalization and
episodic treatment on the continuum of care for the mentally ill;
- Do not require 24 hour care and have an
adequate support system outside the hospital setting while not
actively engaged in the program;
- Have a diagnosis that falls within the
range of ICD-9 codes for mental illness (290-319). However the
diagnosis itself is not the sole determining factor for coverage;
- Are not judged to be dangerous to self or
others.
A Medicare partial hospitalization program is not appropriate for the
following indications:
- Patients who refuse or who cannot
participate with the active treatment process or who cannot tolerate
the intensity of the partial hospitalization program;
- Meals
- Transportation
- Activity therapy if primarily recreational
and diversional
- Programs that are social, recreational or
diversional are not covered. Supervision of older adults in a
"geriatric day care" setting is not covered.
- Community support groups for chronic
mental illness provided in a non-medical setting, or programs that
provide only social interaction are not covered.
- Activities that are primarily recreational
or diversional in nature for which the individual participating does
not have a specific, individual treatment goal. Examples of these
activities include social hours, lunch, television, shopping trips and
attending or participating in sports.
- General education programs or education of
the general public.
- Vocational training is not covered if
related to employment, work skills or work setting.
- Any service that does not have a specific
treatment goal.</UL
1. Medicare provides benefits for Partial Hospitialization:
- Reasonable and necessary for the diagnosis
or active treatment of the individual’s condition; and
- Reasonably expected to improve or
maintain the individual's condition and functional level to prevent
relapse or hospitalization. (See 1861 (ff)(2)(I) of the Social
Security Act.)
2. Two critical points affect the determination of coverage for partial
hospitalization services:
- The initial decision as to the medical appropriateness of
entrance into the program for treatment; and
- The decision about discharge
Both determinations should take into account both the diagnosis and the
individual's treatment needs.
3. Medicare does not have a separate category for substance abuse.
4. The Medicare benefit categories are partial hospitalization services or
outpatient hospital psychiatric services.
5. As there is no separate benefit category for substance abuse programs,
any substance abuse program must meet requirements established for partial
hospitalization programs in order to receive partial hospitalization
reimbursement.
6. Medicare does not have benefit categories for "intensive outpatient
programs" and continuing day treatment programs".
7. The services must be billed as, and meet the requirements of outpatient
hospital psychiatric services or a partial hospitalization program.
8. Partial hospitalization may occur in lieu of either:
- Admission to an inpatient hospital (there
must be evidence of failure at or inability to benefit from a less
intensive outpatient program); or
- A continued inpatient hospitalization
(patients must require PHP services at levels of intensity and
frequency comparable to patients in an inpatient setting for similar
psychiatric illnesses).
9. Treatment may continue until the patient has improved sufficiently to be
maintained in the outpatient or office setting on a less intense and less
frequent basis. This is an individual determination.
10. Patients who require a low frequency of participation may indicate that
the partial program is no longer reasonable and necessary, and the patient
could be managed in an outpatient setting and should no longer be covered
in the partial program.
11. Partial hospitalization services may be covered under Medicare when
they are provided in a hospital outpatient department or a community mental
health (CMHC). A CMHC is a Medicare provider of services only with respect
to the furnishing of partial hospitalization services.
CMS defines a CMHC as an entity that provides:
- Outpatient services, including
specialized outpatient services for children, the elderly,
individuals who are chronically mentally ill, and residents of its
mental health facility.
- 24-hour a day emergency care services
- Screening for patients being considered
for admission to State mental health facilities to decide the
appropriateness of such admission; and
- Consultation and education service.
Individualized
Treatment
A physician must order the partial hospitalization services, establish the
plan of treatment and recertify the need for continued care. Partial
hospitalization services must be prescribed by a physician and furnished
under the supervision of a physician.
Partial hospitalization is active treatment that incorporates an
individualized treatment plan, a coordination of services wrapped around
the clinical needs of the patient and a multi-disciplinary team approach to
patient care. The individualized treatment plan must include, but is not
limited to:
- Physician’s Diagnosis, Axis I through V
- Treatment goals under the plan
- Type of services
- Amount of services
- Duration of services
- Frequency of services
- Rationale for services
- Current functional impairments
(psychological, social, occupational)
- Specific cause of functional impairments
(cognitive, communicative, emotional, psychosocial, behavioral)
- The expected functional outcome
- Long-term goals for each service
provided, including activity therapy, that are directly related to
functional impairments and the expected outcomes.
- Short-term goals for each service
provided that are measurable (e.g symptomatic improvements), functionally
pertinent (e.g., ability for ADL’s), time framed and directly related
to long-term goals
- Medications
- Discharge planning to begin, and be
documented, at the time of admission
- The involvement of the patient, patient’s
family, and/or significant other should be documented and
incorporated into the treatment plan, and
- Community resources that will facilitate
outcome>
The treatment goals are the basis for evaluating the patient’s response to
treatment and should be designed to measure the impact of treatment.
Treatment goals that are measurable and aiming to improve function are the
vital source for the determination of whether a PHP is the appropriate
level of intervention for the individual’s condition.
The level at which treatment goals are accomplished with active treatment,
helps determine the length of the stay in PHP.
The individualized treatment plan is to be established by a physician with
the first 7 days of a patient’s participation in the program. The
individualized treatment plan is to be reviewed weekly by a physician in
consultation with appropriate staff participating in the program. The
physician determines the frequency and duration of services, taking into
account accepted norms of medical practice and a reasonable expectation of
improvement in the patient's condition.
Partial hospitalization is active treatment pursuant to an individualized
treatment plan, prescribed and signed by a physician, which identifies
treatment goals, describes a coordination of services, is structured to
meet the particular needs of the patient, and includes a multidisciplinary
team approach to patient care. The treatment goals described in the
treatment plan should directly address the presenting symptoms and are the
basis for evaluating the patient's response to treatment. The plan should
document ongoing efforts to restore the individual patient to at higher
level of functioning that would permit discharge from the program, or
reflect the continued need for the intensity of the active therapy to maintain
the individual's condition and functional level and to prevent relapse or
hospitalization. Activities that are primarily recreational and
diversionary, or provide only a level of functional support that does not
treat the serious presenting psychiatric symptoms placing the patient at
risk, do not qualify as partial hospitalization services.
12. The program must be prepared to appropriately treat the co-morbid
substance abuse disorder (dual diagnosis patients), when it exists. Dual
diagnosed individuals suffer from concomitant mental illness and chemical
dependency.
13. A patient under the influence of a chemical substance is not capable of
actively participating in PHP..... (random drug screening, AA/NA attendance
and sponsorship, and goals/limit setting are reasonable treatment
modalities)
14. For coverage purposes, the key to whether a particular type or group of
services and activities may be covered as a PHP depends primarily on the
services provided in the program and how the services are being utilized in
the care of the individual patient:
- Individual and group therapy with
physicians or psychologists or mental health professionals to the
extent authorized under State Law;
-
- There is a need to observe the patient’s
interaction with a family member and/or
- There is a need to assess the capability
of family members to aid the patient and aid in the patient’s
management.
Patient training and education, to the extent the training and educational
activities are closely and clearly related to the individual’s care and
treatment.
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