Billing Changes for Partial Hospitalization Programs (PHP) under OPPS

Before the implementation of the Outpatient Prospective Payment System (OPPS) on May 1, 2009, TRICARE policy allowed PHP services to be billed with 90853 for group therapy. Medicare has since made a change in the billing codes used for PHP group therapy. TRICARE has followed Medicare’s lead and also changed its billing codes effective May 1, 2009.

All group therapy should now be billed under HCPCS codes G0410 or G0411.

Providers now need to bill PHP claims with the following information:

1. Mental health/substance abuse diagnosis
2. Bill type 131
3. Condition code 41
4. Appropriate HCPCS/CPT for all services provided in the session; use G0410 and G0411 for group therapy.

Freestanding PHPs will continue to be paid under the all-inclusive per diem rates established under TRICARE Reimbursement Manual Chapter 7, Section 2.

Please refer to the PHP FAQs on www.triwest.com/provider, which can be located in the Claims and Reimbursement/OPPS section of Provider Connection.

Published Date: 09/16/2009