HCPCS H0040: Assertive Community Treatment Program, Per Diem - OpenPayer

Summary & Overview

HCPCS H0040: Assertive Community Treatment Program, Per Diem

HCPCS Level II code H0040 denotes an assertive community treatment (ACT) program billed on a per diem basis, reflecting intensive, team-based psychiatric services delivered in community settings. ACT programs target individuals with serious mental illness who require frequent, coordinated outreach, crisis management, and rehabilitation supports. Nationally, H0040 is important for aligning payment with high-intensity, non-inpatient behavioral health services and for enabling continued community-based care that can reduce hospitalizations.

Key payers considered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical intent and service setting, benchmarks for utilization where available, common billing considerations, and relevant policy and coverage themes affecting per diem behavioral health reimbursement. The publication also highlights how H0040 fits within broader efforts to support community mental health care delivery, program eligibility considerations, and implications for care coordination. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareH0040HCPCS Level IIassertive-community-treatmentbehavioral-healthper-diemcommunity-based-carepsychiatrycase-management

Billing Code Overview

HCPCS Level II code H0040 represents an assertive community treatment program, billed per diem. This service provides intensive, community-based psychiatric care designed to support individuals with serious mental illness through a multidisciplinary team approach.

Service type: Intensive community-based psychiatric treatment, case management, and psychosocial rehabilitation
Typical site of service: Community settings, including patient residences and community locations where outreach and in-home services are delivered

Clinical & Coding Specifications

Clinical Context

An adult with severe, persistent mental illness (for example, schizophrenia or bipolar disorder with frequent relapses and high risk of hospitalization) receives enrollment in an H0040 assertive community treatment (ACT) program. The multidisciplinary ACT team includes psychiatrists, nurse practitioners, licensed clinical social workers, substance use counselors, vocational specialists, and case managers who provide intensive, community-based services. Per diem billing under H0040 covers a day of ACT services and supports: daily medication management, crisis intervention, outreach visits to the patient’s residence or community locations, coordination with primary care, housing stabilization supports, and documentation of team contacts.

A typical workflow: intake and comprehensive assessment are completed by the ACT team; an individualized recovery plan is developed and updated regularly; daily team staffing reviews each active caseload; staff provide in-person or telephonic contacts, medication administration or monitoring, brief therapy, skill-building, and linkage with social services; each calendar day of active ACT service is documented and billed as one unit of H0040 per the payer’s per diem rules. Clinical documentation includes date and duration of team contact, location of service, interventions provided, participant response, and care coordination activities. Ancillary billable services (e.g., medical evaluation, psychotherapy, laboratory testing) are billed separately using appropriate CPT/HCPCS codes when applicable.

Coding Specifications

Modifier	Description

Related Codes

HCPCS-H2032-ACTIVITY-THERAPY-15-MINUTES

HCPCS H2032: Activity Therapy, per 15 minutes

HCPCS-H2020-THERAPEUTIC-BEHAVIORAL-SERVICES-PER-DIEM

HCPCS H2020: Therapeutic Behavioral Services, Per Diem

HCPCS-H0018-SHORT-TERM-RESIDENTIAL-BEHAVIORAL-HEALTH-PER-DIEM

HCPCS H0018: Short-Term Residential Behavioral Health, Per Diem

HCPCS-H0017-RESIDENTIAL-BEHAVIORAL-HEALTH-PER-DIEM-WITHOUT-ROOM-BOARD

HCPCS H0017: Behavioral Health Residential Treatment, Per Diem

HCPCS-H2027-PSYCHOEDUCATIONAL-SERVICE-15-MINUTE

HCPCS H2027: Psychoeducational Service, per 15 Minutes

HCPCS-H2013-PSYCHIATRIC-HEALTH-FACILITY-PER-DIEM

HCPCS H2013: Psychiatric Health Facility Service, Per Diem

HCPCS-H2000-COMPREHENSIVE-MULTIDISCIPLINARY-EVALUATION

HCPCS H2000: Comprehensive Multidisciplinary Evaluation

HCPCS-H2040-COORDINATED-SPECIALTY-CARE-FIRST-EPISODE-PSYCHOSIS-MONTHLY

HCPCS H2040: Coordinated Specialty Care for First Episode Psychosis, Monthly

HCPCS-H2021-COMMUNITY-WRAP-AROUND-SERVICES-15-MINUTES

HCPCS H2021: Community-Based Wrap-Around Services, per 15 Minutes

HCPCS-H0050-BRIEF-ALCOHOL-DRUG-INTERVENTION-15-MINUTES

HCPCS H0050: Alcohol and/or Drug Brief Intervention, per 15 Minutes

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`22`	Increased procedural services	Use when ACT team documents significant additional work beyond typical per diem due to complexity or extended services, and payer allows modifier `22` on per diem billing.
`23`	Unusual anesthesia	Rare for ACT per diem; used only if anesthesia was required in an associated billed service and must be appended to that specific service rather than the per diem.
`52`	Reduced services	Use when ACT provides reduced scope of services for a day (partial-day service) and payer accepts reduced service reporting on per diem claims.
`53`	Discontinued procedure	Use when ACT enrollment or a scheduled intensive service is discontinued for clinical reasons during the billing day and payer guidance permits `53` on per diem claims.
`54`	Surgical care only	Generally not applicable to `H0040`; included if a component of care is carved out and billed separately by a surgeon.
`55`	Postoperative management only	Not typically used with ACT per diem; relevant when another provider bills postoperative follow-up separately.
`62`	Two surgeons	Not applicable to ACT per diem; included for completeness when paired surgical services occur outside ACT.
`CQ`	Service furnished by a psychiatric collaborative care model (per CMS definitions)	Use when a qualifying collaborative psychiatric service is furnished by team members consistent with payer policy and requires CQ modifier.
`FQ`	CRNA service furnished under medical direction of anesthesiologist	Not typically applicable to ACT; included only when anesthesia services are billed alongside ACT services.
`GT`	Via interactive audio and video telecommunications system	Use when ACT services for the day are furnished via telehealth/telepsychiatry in real time and the payer requires `GT` for telehealth per-diem reporting.
`HA`	School-based services — related modifier set	Use when ACT provides school-based outreach services and payer contractual rules require specific school-based modifiers such as `HA`.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals	Not commonly used with ACT; included only with concurrent anesthesia billing.
`QX`	CRNA service with payment modifier — CRNA service furnished without medical direction by an anesthesiologist	Rarely applicable; only relevant to anesthesia billed alongside ACT.
`UB`	Unlisted modifier for behavioral health program-specific reporting	Use where payers require an organizational or program-level modifier template labeled `UB` for billing specialized behavioral health per diems.

Taxonomy Code	Specialty	Notes
`101Y00000X`	Psychiatry & Neurology	Psychiatrists provide medication management and clinical leadership for ACT teams.
`2084P0800X`	Clinical Social Worker	Licensed clinical social workers deliver psychotherapy, case management, and community outreach.
`363L00000X`	Mental Health Counselor	Counselors provide individual and group skills training, relapse prevention, and substance use interventions.
`163W00000X`	Nurse Practitioner	Psychiatric nurse practitioners prescribe and monitor psychotropic medications and provide clinical assessments.
`1193P0207X`	Case Management	Case managers coordinate housing, benefits, and community resources as part of ACT services.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F20.9`	Schizophrenia, unspecified	Schizophrenia is a core diagnosis served by ACT programs for intensive community-based stabilization and relapse prevention.
`F31.9`	Bipolar disorder, unspecified	Bipolar disorder with frequent mood instability often requires ACT-level supports for medication adherence and crisis management.
`F33.1`	Major depressive disorder, recurrent, moderate	Recurrent depression with functional impairment may be managed within ACT when accompanied by high service needs.
`F11.20`	Opioid dependence, uncomplicated	Co-occurring substance use disorders are common in ACT populations; ACT provides coordination for addiction treatment and monitoring.
`F20.81`	Schizoaffective disorder, bipolar type	Schizoaffective disorder patients often require integrated psychiatric and social services provided by ACT teams.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90791`	Psychiatric diagnostic evaluation	Used during initial intake to document diagnostic assessment that informs ACT individualized recovery planning; billed separately from the `H0040` per diem.
`90833`	Psychotherapy, 30 minutes with evaluation and management (E/M) service, office or other outpatient; with E/M	Used when a psychiatrist or advanced practice clinician provides brief psychotherapy in conjunction with an E/M visit during ACT care; billed separately from per diem when documentation supports both services.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Used for discrete medical or psychiatric follow-up visits (medication checks) that meet E/M criteria and are billed separately from the ACT per diem.
`99484`	Care management services, behavioral health integration, per 30 minutes	Used when structured behavioral health care management is provided and billed in addition to ACT per diem if payer permits separate care management billing.
`81002`	Urinalysis without microscopy non-automated dipstick	Used for on-site point-of-care testing related to medication monitoring or substance use screening; billed separately from per diem.