(Medicare Claims Processing Manual)

Beginning with services provided on or after August 1, 2000, payment is made under the hospital outpatient prospective payment system for partial hospitalization services.    For CAHs, payment is made on a 101% reasonable cost basis regardless of the date of service.    In CY 2024, payment for non- excepted off -campus hospital -based PHPs will be made under the MPFS, paying the CMHC per diem rate for APC 5853, for providing up to 3 PHP services per day and APC 5854, for providing 4 or more PHP services per day.    The Part B deductible, if any, and coinsurance apply.   261 - Intensive Outpatient Program Services  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)  Medicare Part B coverage is available for Intensive Outpatient Program (IOP) services on or after January 1, 2024 provided by hospitals, CAHs, CMHCs, RHCs, FQHCs, and Opioid Treatment Programs (OTPs). See chapter 9 in this manual for billing instructions for provider -based and independent RHC/FQHC services. See chapter 39 in this manual for billing instructions for OTPs.  261.1 - Special Intensive Outpatient Program Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    Medicare Part B coverage is available for hospital outpatient intensive outpatient program services.   A. Billing Requirement   Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act defines the services under the intensive outpatient program benefit in a hospital.  Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) recognizes CMHCs as providers of services but only for furnishing intensive outpatient program and partial hospitalization services.  See 261.1.1 of this chapter for CMHC intensive outpatient program bill review directions.   Hospitals and CAHs report condition code 92 in FLs 18- 28 (or electronic equivalent) to indicate the claim is for intensive outpatient program services.  They must also report a revenue code and the charge for each individual covered service furnished.  I n addition, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.  Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under an intensive outpatient program .  In addition, hospital outpatient departments are required to report HCPCS codes.  Component billing assures that only those intensive outpatient program  services covered under 1861(ff) of the Act are paid by the Medicare program.  Effective January 1, 2024, for intensive outpatient program services, non- excepted off -campus provider -based departments of a hospital are required to report a PN modifier on each claim line for non -excepted items and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modifier to be reported with each non- excepted item and service including those for whic h payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.  Effective January 1, 2024, for intensive outpatient program services, excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures, and/or surgeries provided at off -campus provider -based outpatient departments) for all excepted items and services furnished.   All hospitals are required to report condition code 92 in FLs 18- 28 to indicate the claim is for intensive outpatient program services.  Hospitals use bill type 013X and CAHs use bill type 085X.  The following special procedures apply.  Bills must contain an acceptable revenue code.  They are as follows:   Revenue Code  Description  0250  Drugs and Biologicals  043X  Occupational Therapy  0900  Behavioral Health Treatment/Services  0904  Activity Therapy  0910  Psychiatric/Psychological Services (Dates of Service prior to October 16, 2003)  0914  Individual Therapy  0915  Group Therapy  0916  Family Therapy  0918  Behavioral Health/Testing  0942  Education/Training   Hospitals other than CAHs are also required to report appropriate HCPCS codes as follows:   Revenue Code  Description  HCPCS Code  043X  Occupational Therapy  *G0129 ( PHP/IOP ) 0900  Behavioral Health Treatment/Services  ****90791 or ***** 90792, 97153, 97154, 97155, 97156, 97157, 97158  0904  Activity Therapy  **G0176 ( PHP/IOP ) 0914  Individual Psychotherapy  90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90865, 90880, 90899    0915  Group Therapy  G0410 , G0411 , 90853    0916  Family Psychotherapy  90846 , 90847 , 90849  0918  Behavioral Health/Testing  96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96161, 96164, 96167, 97151, 97152  0942  Education/Training  G0023, G0024, G0140, G0146, ***G0177, G0451, 96202, 96203, 97550, 97551, 97552  The A/B MAC (A) will edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  The A/B MAC (A) will not edit for matching the revenue code to HCPCS.   *The definition of code G0129 is as follows:   Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization or intensive outpatient  treatment program, per session (45 minutes or more).   **The definition of code G0176 is as follows:   Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patients disabling mental problems, per session (45 minutes or more).   ***The definition of code G0177 is as follows:   Training and educational services related to the care and treatment of patients disabling mental health problems, per session (45 minutes or more).   ****The definition of code 90791 is as follows:   Psychiatric diagnostic evaluation (no medical services) completed by a nonphysician.  *****The definition of code 90792 is as follows:   Psychiatric diagnostic evaluation (with medical services) completed by a physician.  Codes G0129 and G0176 are used only for intensive outpatient programs or partial hospitalization programs.   Code G0177 may be used in intensive outpatient programs, partial hospitalization programs, and outpatient mental health settings.  Revenue code 0250 does not require HCPCS coding.  However, Medicare does not cover drugs that can be self -administered.   Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  Do not edit for the matching of revenue code to HCPCS.   B. Professional Services   The professional services listed below when provided in all hospital outpatient departments are separately covered and paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practitione rs (other than physician assistants (PA)) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient intensive outpatient program patients.  The hospital can also serve as a billing agent for these professionals by billing the A/B MAC (B) on their behalf under their billing number for their professional services.  The professional services of a PA can be billed to the A/B MAC (B) only by the PA's employer.  The employer of a PA may be such entities or individuals a s a physician, medical group, professional corporation, hospital, SNF, or nursing facility.  For example, if a physician is the employer of the PA and the PA renders services in the hospital, the physician and not the hospital would be responsible for bill ing the A/B MAC (B) on Form CMS -1500 for the services of the PA.  The following direct professional services are unbundled and not paid as intensive outpatient program services.    Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;    Physician assistant (PA) services as defined in 1861(s)(2)(K)(i) of the Act;    Nurse practitioner and clinical nurse specialist services, as defined in 1861(s)(2)(K)(ii) of the Act; and    Clinical psychologist services as defined in 1861(ii) of the Act.   The services of other practitioners (including clinical social workers , marriage and family therapists, mental health counselors, and occupational therapists) are bundled when furnished to hospital patients, including intensive outpatient program patients.  The hospital must bill the contractor for such nonphysician practitioner services as partial hospitalization services.  Make pa yment for the services to the hospital.  C. Outpatient Mental Health Treatment Limitation   The outpatient mental health treatment limitation may apply to services to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CNSs, and PAs to intensive outpatient program patients.  However, the outpatient mental health treatment limitation does not  apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC or hospital outpatient department as intensive outpatient program services.  D. Reporting of Service Units   Hospitals report the number of times the service or procedure, as defined by the HCPCS code, was performed. CAHs report the number of times the revenue code visit was performed.   NOTE : Service units are not required to be reported for drugs and biologicals (Revenue Code 0250).  E. Line Item Date of Service Reporting   Hospitals other than CAHs are required to report line item dates of service per revenue code line for intensive outpatient program claims.  This means each service (revenue code) provided must be repeated on a separate line item along with the specific dat e the service was provided for every occurrence.  Line item dates of service are reported in FL 45 Service Date (MMDDYY).  See 260.5 for a detailed explanation.  F. Payment   Starting in CY  2024 and subsequent years, the payment structure for intensive outpatient program services provided in hospital outpatient departments and CMHCs has been set to four (4) separate APCs.  Community Mental Health Center IOP APCs 5851 (Level 1 I ntensive Outpatient Program (up to 3 services)) and 5852 (Level 2 Intensive Outpatient Program (4 or more services)) and Hospital -based IOP APCs 5861 (Level 1 Intensive Outpatient Program (up to 3 services)) and 5862 (Level 2 Intensive Outpatient Program ( 4 or more services)).  The following chart displays the CMHC and hospital -based IOP  APCs:   Hospital -Based and Community Mental Health Center IOP APCs  CY 2024 APC  Group Title  5851  Intensive Outpatient Program (up to 3 services per day) for CMHC IOPs  5852  Intensive Outpatient Program (4 or more services per day) for CMHC IOPs  5861   Intensive Outpatient Program (up to 3 services per day) for hospital -based IOPs  5862  Intensive Outpatient Program (4 or more services per day) for hospital -based IOPs    Apply Part B deductible, if any, and coinsurance.   G. Data for CWF and PS&R   Include revenue codes, HCPCS/CPT codes, units, and covered charges in the financial data section (fields 65a 65j), as appropriate.  Report the billed charges in field 65h, "Charges," of the CWF record.   Include in the financial data portion of the PS&R UNIBILL, revenue codes, HCPCS/CPT codes, units, and charges, as appropriate.   Future updates will be issued in a Recurring Update Notification.   261.1.1 - Bill Review for Intensive Outpatient Program Services Provided in Community Mental Health Centers (CMHC)  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)   A. General