LCD ID Number: L33626 Status: A-Approved
LCD Title: Psychiatric Partial Hospitalization Programs
Geographic Jurisdiction: Illinois Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Sections 1861 (ff) and 1832 (a)of Title XVIII of the Social Security Act define the partial hospitalization benefit and provide for coverage of partial hospitalization in a hospital or CMHC setting. Section 1861 (ff) also provides coverage of partial hospitalization in a Critical Access Hospital (CAH) outpatient setting.
Section 1861 (s)(2)(B) of Title XVIII of the Social Security Act references partial hospitalization in a hospital outpatient setting.
Section 1835(a) of Title XVIII of the Social Security Act references physician certification.
Section 1833(e) of Title XVIII of the Social Security Act requires services to be documented in order for payment to be made.
Code of Federal Regulations:
42 CFR Section 410.43 describes conditions and exclusions from partial hospitalization services.
42 CFR Section 424.24 lists requirements for certification of partial hospitalization services.
Federal Register, Vol. 59, No. 29, February 11, 1994, pages. 6570-6579 is the Partial Hospitalization Services in Community Mental Health Centers Interim Final Rule.
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2:
30.2.2 Active Treatment in Psychiatric Hospitals
126.96.36.199 Principles for Evaluating a Period of Active Treatment
30.2.3 Services Supervised and Evaluated by a Physician
30.3.1 Individualized Treatment or Diagnostic Plan
30.3.2 Services Expected to Improve the Condition or for Purpose of Diagnosis
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6:
70 Outpatient Hospital Psychiatric Services
70.3 Partial Hospitalization Services
CMS Publication 100-03, Medicare National Coverage Determinations Manual (MNCDM), Chapter 1:
70.1 Consultations With a Beneficiary's Family and Associates
160.25 Multiple Electroconvulsive Therapy (MECT)
170.1 Institutional and Home Care Patient Education Programs
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 4:
260 Outpatient Partial Hospitalization Services
260.1 Hospital Outpatient Partial Hospitalization Services Billing Requirements
260.1.1 Bill Review for Partial Hospitalization Services Provided in Community Mental Health Centers (CMHC)
260.2 Professional Services Related to Partial Hospitalization
260.3 Outpatient Mental Health Treatment Limitations for Partial Hospitalization Services
260.4 Reporting Service Units for Partial Hospitalization
260.5 Line Item Date of Service Reporting for Partial Hospitalization
260.6 Payment for Partial Hospitalization Services
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
150 Clinical Social Worker (CSW) Services
160 Independent Psychologist Services
160.1 Payment [for testing services performed by psychologists other than clinical psychologists]
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