(Medicare Claims Processing Manual)

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   Medicare Part B coverage for intensive outpatient program services provided by CMHCs is available for services provided on or after January 1, 2024.  B. Special Requirements   Section 1866(e)(2)  (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm) of the Act recognizes CMHCs as providers of services but only for furnishing intensive outpatient program and partial hospitalization services.  Applicable provider ranges are 14001499, 46004799, and 49004999.  C. Billing Requirements   CMHCs bill for intensive outpatient program services under bill type 076X.  All CMHCs are required to report condition code 92 in FLs 18- 28 to indicate the claim is for intensive outpatient program services.  The following special procedures apply.  The A/B MACs (A) follow bill review instructions in chapter 25 of this manual, except for those listed below.  The acceptable revenue codes are as follows:   Revenue Code  Description  0250  Drugs and Biologicals  043X  Occupational Therapy  0900  Behavioral Health Treatments/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   CMHCs are also required to report appropriate HCPCS codes as follows:   Revenue Codes  Description  HCPCS Code  043X  Occupational Therapy  *G0129 ( PHP/IOP ) 0900  Behavioral Health Treatments/Services  ****90791 or *****90792 , 97153, 97154, 97155, 97156, 97157, 97158   Revenue Codes  Description  HCPCS Code  0904  Activity Therapy  **G0176 ( PHP/IOP )    0914  Individual Psychotherapy  90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90865, 90880, 90899   0915  Group Psychotherapy  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(s) (A) edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  They do not edit for the matching of revenue codes to HCPCS.   Definitions of each of the asterisked HCPCS codes follow:   *The definition of code G0129 is as follows:  Occupational therapy services requiring the 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 health 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 program and 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, drugs that can be self -administered are not covered by Medicare.   HCPCS includes CPT -4 codes.  See the ASC X12 837 institutional claim guide for how to report HCPCS electronically.  CMHCs report HCPCS codes on Form CMS -1450 in FL44, HCPCS/Rates.  HCPCS code reporting is effective for claims with dates of service on or after April 1, 2000.  The A/B MACs (A) are to advise their CMHCs of these requirements.  CMHCs should complete the remaining items on the claim in accordance with the ASC X12 837 Institutional Claim implementation guide and the Form CMS -1450 instructions in Chapter 25 of this m anual.  The professional services listed below are separately covered and are paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practitioners (other than physician assistants (PAs)) bill t he A/B MAC (B) directly for the professional services furnished to CMHC intensive outpatient program patients.  The ASC X12 837 professional claim format or the paper form 1500 is used.  The CMHC can also serve as a billing agent for these professionals by billing the A/B MAC (B) on their behalf 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 as 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 CMHC, the physician and not the CMHC would be responsible for billing the A/B MAC (B) for the services  of the PA.   The following professional services are unbundled and not paid as partial hospitalization services:    Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;    PA services, as defined in 1861(s)(2)(K)(i) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act;    Nurse practitioner and clinical nurse specialist services, as defined in 1861(s)(2)(K)(ii) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act; and,    Clinical psychologist services, as defined in 1861(ii) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act.  The services of other practitioners (including clinical social workers and occupational therapists) are bundled when furnished to CMHC patients.  The CMHC must bill the A/B MAC (A) for such nonphysician practitioner services as intensive outpatient program  services.  The A/B MAC (A) makes payment for the services to the CMHC.   D. 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) as intensive outpatient program services.   E. Reporting of Service Units   Visits should no longer be reported as units.  Instead, CMHCs report in the field, Service Units, the number of times the service or procedure, as defined by the HCPCS code, was performed when billing for intensive outpatient program services identified by revenue code in subsection C.  EXAMPLE:  A beneficiary received psychological testing performed by a physician for a total of 3 hours during one day (HCPCS code 96130, first hour; HCPCS code 96131 for 2 additional hours).  The CMHC reports revenue code 0905, HCPCS code 96130, and 1 unit; and a se cond line on the claim showing revenue code 0905, HCPCS code 96131, and 2 units.  When reporting service units for HCPCS codes where the definition of the procedure does not include any reference to time (either minutes, hours, or days), CMHCs should not bill for sessions of less than 45 minutes.  The CMHC need not report service units for drugs and biologicals (Revenue Code 0250).   NOTE : Information regarding the Form CMS -1450 form locators that correspond with these fields is found in Chapter 25 of this manual.  See the ASC X12 837 Institutional Claim implementation guide for related guidelines for the electronic claim.   F. Line Item Date of Service Reporting   Dates of service per revenue code line for intensive outpatient claims that span two or more dates.  This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the service was provided for every occurrence.  Line item dates of service are reported in Service Date.  See examples below of reporting line item dates of service.  These examples are for group therapy services provided twice during a billing period.  For claims, report as follows:   Revenue Code  HCPCS Dates of Service  Units Total Charges 0915  G0410  20240505 1 $80 0915  G0410  20240529 2 $160   NOTE : Information regarding the Form CMS -1450 form locators that correspond with these fields is found in Chapter 25 of this manual.  See the ASC X12 837 Institutional Claim Implementation Guide for related guidelines for the electronic claim.   The A/B MACs (A) return to provider claims that span two or more dates if a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement covers period.  Line item date of service reporting is effective for claims with dates of service on or after June 5, 2000.  G. Payment   Section 1833(a)(2)(B) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm )  of the Act provides the statutory authority governing payment for intensive outpatient program services provided by a CMHC.  A/B MAC(s) (A) make payment under OPPS.  The Part B deductible and coinsurance applied.   Payment principles applicable to intensive outpatient program services furnished in CMHCs are contained in 2400 of the Medicare Provider Reimbursement Manual.  The A/B MACs (A) make payment on a per diem basis under the hospital outpatient prospective payment system for intensive outpatient program services.  CMHCs must continue to maintain documentation to support medical necessity of each service provided, including the beginning and ending time.  Effective January 1, 2024, there are four separate APC payment rates for IOP:  two for CMHCs (for Level I and Level II services based on only CMHC data) and two for hospital -based PHPs (for Level I and Level II services based on only hospital -based IOP data).    The two CMHC APCS for providing intensive outpatient program services are:  APC 5851 (Level 1 intensive outpatient program (up to 3 services)) and APC 5852 (Level 2 intensive outpatient program (4 or more services)).    Community Mental Health Center IOP APC  APC  Group Title  5851  Intensive Outpatient Program (3 or more services per day) for CMHCs  5852  Intensive Outpatient Program (4 or more services per day) for CMHCs