Filing Claims for PHP Charges

Psychological testing conducted while a beneficiary is in an approved PHP will be considered included in the facility’s per diem rate. PHP care must be billed on a UB-04:

• Revenue Code 912—Psychiatric Partial Hospitalization, all-inclusive per diem payment of three to five hours (half day)
• Revenue Code 913—Psychiatric Partial Hospitalization, all-inclusive per diem payment of six or more hours (full day)

Effective May 1, 2009, the TRICARE OPPS pays claims filed for hospital outpatient services, including hospital-based PHPs (psychiatric and SUDRFs) subject to TRICARE’s prior authorization requirements. Freestanding PHPs (psychiatric and SUDRFs) will continue to be reimbursed under the existing PHP per diem payment. TRICARE OPPS is mandatory for both network and non-network providers.

TRICARE has adopted Medicare’s PHP reimbursement methodology for hospital-based PHPs. There are two separate APC payment rates under this reimbursement methodology:

• APC 0172: For days with three services
• APC 0173: For days with four or more services

Additionally, TRICARE allows physicians, clinical psychologists, clinical nurse specialists, NPs, and PAs to bill separately for their professional services delivered in a PHP. The only professional services that are included in the PHP per diem payment are those furnished by clinical social workers, occupational therapists, and alcohol and addiction counselors.

To bill for partial hospitalization services under the hospital-based OPPS, hospitals are to use the appropriate HCPCS codes and revenue codes and report partial hospitalization services under bill type 013X, along with condition code 41 on the UB-04 claim form. The revenue code and HCPCS code must be billed separately for each date of service. The claim must also include a behavioral health diagnosis and an authorization on file for each day of service, along with the designated H code and its accompanying revenue code as previously listed, regardless of OPPS or freestanding status.

For more information about how OPPS affects TRICARE PHPs and for a complete listing of applicable revenue and HCPCS codes, refer to the TRICARE Reimbursement Manual, Chapter 13, Section 2, or contact Humana Military’s toll-free customer service line at 1-800-444-5445.