Does G0176 require prior authorization?

No, G0176 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for G0176?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`G0176`, Activity therapy, such as music, dance, art or play therapies not for

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Billing, coding, and required claim documentation must follow the requirements specified in LCD L37633 (see that LCD for required medical records, prior authorization, and claim submission documentation).
Medical record must document medical necessity for services including relevant medical history, physical exam, and pertinent diagnostic test results supporting the LCD indications and limitations.

On admission the physician (MD/DO) must sign a certification that the patient would require inpatient psychiatric hospitalization without PHP and attest that services are furnished under physician care and an individualized written plan of care.

First recertification must be signed by the treating physician on or by the 18th day of PHP and subsequent recertifications must be signed by the treating physician at intervals no less frequently than every 30 days.

Recertification must state that without continued PHP the patient would require inpatient psychiatric care and must describe response to interventions, ongoing risk of hospitalization, and treatment goals for discharge coordination.

Initial psychiatric evaluation documentation (within 48 hours) must include chief complaint; description of acute/exacerbation; current medical history and meds including failure of less intensive outpatient care; past psych/medical history; substance abuse history; family/vocational/social history; mental status exam; physical exam (if not available within 30 days); formulation and treatment plan; ICD-10/DSM diagnosis.

Key Coverage Criteria

Partial Hospitalization Program services that meet the coverage criteria of Local Coverage Determination L37633 are considered covered.
Patient requires active psychiatric partial hospitalization (PHP) with an individualized written plan of care developed by a physician in consultation with appropriate staff and a multidisciplinary team.
Patient requires a minimum of 20 hours per week of therapeutic services as evidenced by the plan of care.
On admission, a physician (MD/DO) certifies that the patient would require inpatient psychiatric hospitalization if PHP services were not provided and attests that services are furnished while the patient is under physician care.
Initial psychiatric evaluation (including medical history and physical examination) is performed and placed in the chart within 48 hours of admission to establish medical necessity.
Diagnosis coding (ICD-10-CM) that best describes the patient's condition is required on the claim to support medical necessity.

16 Active Policies

CGS-J15-L34196, Psychiatric Partial Hospitalization Programs

J15

CGS-J18-L34196, Psychiatric Partial Hospitalization Programs

J18

A56850, Billing and Coding: Psychiatric Partial Hospitalization Programs

NGS-J6-L33626, Psychiatric Partial Hospitalization Programs

NGS-JK-L33626, Psychiatric Partial Hospitalization Programs

AETNA-CPB-0388, Complementary and Alternative Medicine

AETNA-CPB-0614, Huntington's Disease

AETNA-CPB-0078, Learning Disabilities, Dyslexia, and Vision

AETNA-CPB-0406, Tinnitus Treatments

CIGNA-0447, Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment

AMBETTER-CP.BH.124, Attention Deficit Hyperactivity Disorder Assessment and Treatment

CIGNA-EN0086, Complementary and Alternative Medicine

ANTHEM-CG-BEH-15, Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

A56685, Billing and Coding: Partial Hospitalization Programs

A57053, Billing and Coding: Psychiatric Partial Hospitalization Programs

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

`G0176`, Activity therapy, such as music, dance, art or play therapies not for

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

G0176, Activity therapy, such as music, dance, art or play therapies not for

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`G0176`, Activity therapy, such as music, dance, art or play therapies not for