KMAP BULLETIN: Partial Hospitalization Psychiatric Care/Intensive Outpatient Treatment: Eating Disorder Care – Enrollment and Coverage
Date: 04/11/25
KMAP GENERAL BULLETIN 25063 (PDF)
Effective with dates of service retroactive to January 1, 2025, the Partial Hospitalization Psychiatric (PHP) Care and Intensive Outpatient Treatment (IOP) for Eating Disorder Care shall be provided by providers enrolled with Kansas Medical Assistance Program (KMAP) to individuals meeting medical necessity, with a mental health diagnosis for an eating disorder.
Covered Services:
Coverage provided is limited to medically necessary treatment that is provided under the direction of a licensed treating physician and in accordance with a treatment plan. Services shall be provided for maximum reduction of physical or mental disability and restoration of a beneficiary to their best possible functional level.
The following are the covered services and must be billed with allowable diagnoses listed below:
| Code | Rate (per day) | Benefit Limits |
|---|---|---|
| H0035 (PHP) | $750 |
|
| S9480 (IOP) | $550 |
|
Note: The rates noted in this bulletin may change in the future. Providers should check the KMAP website for the most up-to-date rates.
Allowable Mental Health Diagnoses for Eating Disorder:
The care management for the treatment of eating disorders shall consider the overall medical and mental health needs of the individual with an eating disorder, shall not be based solely on weight, and preserves the patient’s dignity to the greatest extent possible.
The following diagnosis should be associated to individuals receiving care and of which may be co-occurring:
| Diagnosis Type | Diagnosis Code Range |
|---|---|
| Eating Disorder | F50.00 - F50.29 (Anorexia Nervosa) F50.2 - F50.25 (Bulimia Nervosa) F50.8 - F50.9 (Other eating disorders) |
Covered Provider Types/Provider Specialties (PT/PS):
The following are the covered PT/PS:
| PT/PS | Specialty Description |
|---|---|
| 01/011 | Psychiatric Hospital |
| 11/021* | PHP Care/IOP Treatment |
*Mental health providers should enroll under new provider specialty 021 using taxonomy 261QM0801X.
Enrollment Requirements for Provider Specialty 021:
- Organizations shall hold a National Accreditation from a one of these nationally recognized entities with a Behavioral Health Accreditation attachment.
- The Joint Commission (TJC) or
- Commission on Accreditation of Rehabilitation Facilities (CARF)
- Enrolled and credentialed as a Kansas Medicaid Provider
- Form W-9
- Organizations shall ensure all professional staff are licensed in the State of Kansas and all paraprofessional staff are appropriately certified and trained.
- Billing Guidelines:
Psychiatric hospitals (PS 011) may bill for PHP or IOP services using its existing taxonomy codes: 273R00000X (Hospital Units/Psychiatric Unit) or 283Q00000X (Hospitals/Psychiatric Hospital). - Mental health providers (PS 021) may bill for PHP or IOP services using taxonomy code 261QM0801X (Ambulatory Health Care Facilities/Clinic/Center/Mental Health [including Community Mental Health Center]).
- PHP Care – Code H0035:
- Allowed one unit per day.
- A maximum of 5 days shall be billed per week services for a minimum of 20 hours per week and would require inpatient psychiatric care if the partial hospitalization services were not provided
- IOP Treatment – Code S9480:
- Allowed one unit per day.
- A minimum of 2 service components (refer to core components section below) per session to achieve 9 to 19 hours of intervention per week for adults (18 yrs. +) and 6 to 19 hours of intervention per week for youth (ages 6-17 yrs).
- Below services are not reimbursable with IOP services:
- Addiction and Recovery Treatment Services at American Society of Addiction Medicine (ASAM) levels 2.1‐4.0: H0005 U5, H0004, H0018, H0015 U5, H0019
- Opioid Based Outpatient Treatment Services: 80348, G2086, G2087, G2088, H0005, H0001, H0005 U5, H0006, H0006 U5, H0004, H0015 U5, H0007, J0570 J0571, J0572, H0015, J0575, J0573, J2315, Q9991, J0574
- Psychosocial Rehabilitation: H2017, H2017TJ, H2017HQ
- Assertive Community Treatment: H0040
- Psychiatric Residential Treatment: T2048
- Inpatient Admissions
Note: Providers may submit a claim for:
- Psychiatric evaluation services 90791 or 90792 when provided by qualified professional staff when an individual does not meet program admission criteria.
- Crisis Psychotherapy 90839 and 90840 when provided outside of program hours to an individual of the program.
Noncovered Services:
The following are not covered:
- Meals and transportation
- Activity therapies
- Group activities or other services and programs which are primarily recreational or diversional in nature
- Outpatient psychiatric day treatment programs that consist entirely of activity therapies
Staffing Ratios:
Staffing should not exceed one staff member per five individuals in the program. Clinical supervision of staff should not exceed one supervisor for six direct care workers.
Core Service Components:
Core Components should include:
- Screening, intake, and assessment services,
- Referral services,
- Emergency psychiatric services,
- Emergency and routine medical services,
- Physician services,
- Nursing services,
- Psychotherapy services (Individual/ Group/Family); and
- Dietary services.
Treatment Plan:
- Services shall be based on a comprehensive, coordinated, and individualized treatment plan, and services shall involve the use of multiple, concurrent interventions and treatment modalities.
- Address the underlying causes of the eating disorder, develop coping skills, promote recovery, and reduce the need for a more acute level of care.
- Core services shall be available to individuals on a daily basis, either as part of routine or emergency care.
- The treatment plan shall include, but is not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals.
Recertification Requirements PHP:
The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. The first recertification is required as of the 18th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days. The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following:
- The patient's response to the therapeutic interventions provided by the partial hospitalization program.
- The patient's psychiatric symptoms that continue to place the patient at risk of hospitalization.
- Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program.
Recertification Requirements IOP:
The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. Recertifications are required at intervals established by the provider, but no less frequently than every 60 days. The recertification must specify that the patient continues to require at least 9 hours of intensive outpatient services and describe the following:
- The patient's response to the therapeutic interventions provided by the intensive outpatient program.
- The patient's psychiatric symptoms that continue to place the patient at risk of relapse or hospitalization.
- Treatment goals for coordination of services to facilitate discharge from the intensive outpatient program.
Note: The effective date of the policy is January 1, 2025. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.
For changes resulting from this bulletin, view the updated Hospital Fee-for-Service Manual, pages 8-64 through 8-68 and Mental Health Fee-for-Service Manual, pages 8-20 through 8-24.