(Medicare Claims Processing Manual)

**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 patient s 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 patient s 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 (P A)) 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 P A can be billed to the A/B MAC (B) only by the P A's employer.  The employer of a P A 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 P A and the P A 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 P A.  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 (P A) 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 payment 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 P As 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 65a65j), 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 patient s 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 patient s 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 (P As)) 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 P A can be billed to the A/B MAC (B) only by the P A's employer.  The employer of a P A 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 P A 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 P A.  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;    P A services, as defined in 1861(s)(2)(K)(i) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act;