CMS to Enforce 20 hrs. per Week Therapeutic Services with Weekly Billing Requirement

Patients admitted to a partial hospitalization program (PHP) must be under the care of a physician who certifies the need for partial hospitalization and that the patient requires a minimum of 20 hours per week of therapeutic services, evidenced by their plan of care. PHP patients also require comprehensive, structured, multimodal treatment with medical supervision and coordination, provided under an individualized plan of care, due to a mental disorder which severely interferes with multiple areas of daily life – including social, vocational, and/or educational functioning. That dysfunction generally is acute. Additionally, PHP patients must be able to cognitively and emotionally participate in the active treatment process, and capable of tolerating the intensity of a PHP program.
To enforce the requirement of a minimum of 20 hours per week of therapeutic services, CMS is incorporating three (3) new edits into its Integrated Outpatient Code Edits (IOCE) for its quarterly release in July 2016. These new edits will enforce a weekly billing requirement.

CMS is giving advance notice of this new weekly billing requirement so PHP providers can prepare their systems to submit claims correctly and plan accordingly.

Below is a table from CMS’ MLN Article showing the IOCE Edit Codes, the FISS Reason Code, a narrative explanation of what the code means, and disposition of the claim. The article may be accessed at:

July 2016 IOCE Editing

IOCE Edit FISS Reason Code Narrative Disposition
95 W7095 Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service RTP Claim
96 W7096 Partial hospitalization interim claim from and through dates must span more than 40 days RTP Claim
97 W7097 Partial hospitalization services are required to be billed weekly RTP Claim

Initially, during the first quarter, all edits will be set up to “Return to Provider (RTP)”. After the first quarter, CMS will set the IOCE Edit Code 95 to deny the claims.

Sullivan Stolier Schulze & Grubb has assisted its clients for many years with Medicare and Medicaid reimbursement, compliance and other healthcare regulatory issues.