Who We Serve · PHP
Partial Hospitalization Program (PHP) Billing
The Level of Care
What Makes PHP Billing Different
At a glance
- Per-diem billing with a payer-dependent HCPCS code
- Neither H0035 nor S0201 is payable by Medicare
- Medicare pays PHP institutionally, on its own code set
- H0035 and S0201 never belong on the same claim for the same date
Reference
PHP Billing Codes
What’s Included
PHP Billing Services From CodeMax
Payer-specific model confirmation
CodeMax confirms which billing model each payer expects, H0035, S0201, or Medicare’s institutional code set, before claims go out, rather than applying one default across every payer.
Program hour and service tracking
Daily program hours and services delivered are tracked as they happen, so the documentation supports the intensity level billed rather than being reconstructed after the fact.
Authorization and reauthorization tracking
PHP’s typically shorter reauthorization cycles are tracked so a program doesn’t run past its authorized days before the next review is submitted.
Denial management
Denials tied to wrong-code submissions, H0035 billed to a payer expecting S0201 or the reverse, or to a per-diem code billed to Medicare, are worked and appealed with supporting documentation.
Documentation review
Program-hour and service documentation is reviewed against what’s billed before submission to confirm it supports PHP-level intensity specifically.
Step-Down
PHP to IOP or Residential: What Changes at the Transition
Why CodeMax
The Right Code Combination, Per Payer
FAQ
Partial Hospitalization Program Billing: Frequently Asked Questions
No, and this is where most PHP denials start. Many Medicaid programs require H0035 while many commercial payers require S0201. Neither is payable by Medicare: both carry CMS coverage status “I,” and Medicare instead pays PHP institutionally, reporting individual service lines with condition code 41 under its outpatient prospective payment system. Confirming the model per payer rather than applying one default is what prevents denials here.
They distinguish program intensity: 0912 is the less intensive partial hospitalization revenue code and 0913 the intensive one. They are used on commercial and Medicaid institutional claims. Medicare does not accept either for PHP; it uses a different revenue code set and separately determines payment based on whether three or four or more services are furnished in the day. That services-per-day rule is a Medicare payment mechanic, not the definition of 0912 and 0913.
PHP typically requires more hours of programming per day (often five days a week) than IOP, and uses a different code set: H0035 or S0201 with revenue codes 0912 and 0913 for PHP, versus S9480 or H0015 with revenue codes 0905 and 0906 for IOP. Medicare treats them as two separate benefits with different certification thresholds, 20 hours a week for PHP and 9 for IOP. See the IOP page for that level’s codes.
Yes. Facilities offering a full continuum of care are common, and billing needs to reflect the correct level, code set, and transition dates accurately whenever a patient steps between programs.
For Medicare the requirements are specific: a physician certification that the patient would require inpatient psychiatric hospitalization without the program, at least 20 hours per week of therapeutic services, a physician-signed plan of care, recertification by the 18th day and at least every 30 days after that, and a reasonable expectation of improvement through active treatment. Commercial payers apply their own criteria, most often MCG or InterQual for mental health and ASAM Level 2.5 for substance use, and their hour thresholds do not necessarily match Medicare’s.
No. They should never both appear on the same claim for the same date of service; one or the other applies depending on the payer.
Billing the wrong model for the payer type, most often a per-diem HCPCS code sent to Medicare or H0035 sent to a payer that expects S0201. After that, documentation that does not evidence PHP-level intensity for the days billed.
Yes. The codes are the same, with modifier HA identifying a child or adolescent program, but the surrounding requirements differ: separate state licensure, documented family therapy as a condition of payment in many state Medicaid programs, and EPSDT, which requires coverage of medically necessary services for Medicaid enrollees under 21 even where the adult benefit would not reach. Adolescent weekly hour thresholds are also frequently lower than adult thresholds.
