(Medicare Claims Processing Manual)

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;    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 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) 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 s ervice 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   NOTE:  Occupational therapy services provided to Intensive Outpatient Program for CMHCs' patients are not subject to the prospective payment system for outpatient rehabilitation services, and therefore the financial limitation required under 4541 of the Balanced Budget Act (BBA) doe s not apply.  H. Medical Review   The A/B MACs (A) follow medical review guidelines in Pub. 100- 08, Medicare Program Integrity Manual.  I. Coordination with CWF   See chapter 27 of this manual.   261.2 - Professional Services Related to Intensive Outpatient Program  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   The professional services listed below when provided in a hospital or CAH outpatient department are separately covered and paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practit ioners (other than physician assistants (P A)) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient partial hospitalization patients.  The hospitals or CAHs can also serve as a billing agent for these profess ionals by billing the A/B MAC (B) on their behalf under their billing number for their professional services.  Only a PA s employer can bill the A/B MAC (B) for professional services of a 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 or CAH patients, including intensive outpatient program  patients.  The hospital or CAH must bill their A/B MAC (A) for such nonphysician practitioner services as intensive outpatient program  services.  Payment is made to the provider for these services.   Only the actual employer of the P A can bill for these services.  The employer of a P A may be such entities or individuals such 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 hospital or CAH, the physician and not the hospital or CAH is responsible for billing the A/B MAC (B) on the Form CMS-1500 for the services of the P A.   261.3 - Outpatient Mental Health Treatment Limitation for Intensive Outpatient Program Services  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   The outpatient mental health treatment limitation applies to services to intensive outpatient program  patients to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CAHs, and P As.  It does not apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC, hospital, or CAH  as intensive outpatient program  services.   261.4 - Reporting Service Units for Intensive Outpatient Program  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)  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 .  EXAMPLE:  A beneficiary received psychological testing (HCPCS code 96100 which is defined in one -hour intervals) for a total of three hours during one day.  The hospital reports revenue code 0905 in FL 42, HCPCS code 96100 in FL 44, and three units in FL 46.  The CAH would report revenue code 0918, leave HCPCS blanks, and report 1 unit in FL 46.  When reporting service units for HCPCS codes where the definition of the procedure does not include any reference to time (either in minutes, hours, or days), hospital outpatient departments do not bill for sessions of less than 45 minutes.  The A/B MAC (A) must return to the provider claims other than CAH claims that do not contain service units for each HCPCS code.   NOTE:  Service units do not need to be reported for drugs and biologicals (Revenue Code 0250).  Hospitals must retain documentation to support the medical necessity of each service provided, including beginning and ending time.  261.5 - Line Item  Date of Service Reporting for Intensive Outpatient Program  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)  Hospitals other than CAHs are required to report line item  dates of service per revenue code line for intensive outpatient program  claims.  Where services are provided on more than one day included in the billing period, the date of service must be identified.  Each service (revenue code) provided must be repeated on a separate line item along with the specific date the service was p rovided for every occurrence.  See examples below of reporting line item dates of service.  These examples are for group therapy services provided twice during a billing period.   For the claims, report as follows:   Revenue Code  HCPCS  Dates of Service  Units  Total Charges  0915  G0410  20240505  1 $80.00  0915  G0410  20240529  2 $160.00   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 MAC (A) must return to the hospital (RTP) claims where 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.    261.6 - Payment for Intensive Outpatient Program Services  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   Beginning with services provided on or after January 1, 2024, the A/B MAC (A) makes payment for hospital outpatient departments under the hospital outpatient prospective payment system for intensive outpatient program services. The Part B deductible and coinsurance apply.  For CAHs, payment is made on a 101% reasonable cost basis.