(Medicare Claims Processing Manual)

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) does 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 (PA)) 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 PAs employer can bill the A/B MAC (B) for professional services of a 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 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 PA can bill for these services.  The employer of a PA 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 PA 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 PA.   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 PAs.  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 thera py 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.   In CY 2024, payment for non- excepted off -campus hospital -based IOPs will be made under the MPFS, paying the CMHC per diem rate for APC 5851, for providing up to 3 IOP services per day and APC 5852, for providing 4 or more IOP services per day.   The Part B deductible, if any, and coinsurance apply.    270 - Billing for Hospital Outpatient Services Furnished by Clinical Social Workers (CSW)  Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs)  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)   Payment may be made for covered diagnostic and therapeutic services furnished by CSWs, MFTs, and MHCs in a hospital outpatient setting.  CSW, MFT, and MHC services furnished under a partial hospitalization program are included in the partial hospitalizatio n rate.  CSW, MFT, and MHC services furnished under an intensive outpatient program are included in the intensive outpatient rate.  Other CSW, MFT, and MHC services must be billed to the A/B MAC (B) on Form CMS -1500 or the electronic equivalent.    See chapters 13 and 15, of the Medicare Benefit Policy Manual, for a discussion of the coverage requirements for CSWs, MFTs, and MHCs.     270.1 - Fee Schedule to be Used for Payment for CSW Services  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    The fee schedule for CSW services is set at 75 percent of the fee schedule for comparable services furnished by clinical psychologists, except for services under a CAH partial hospitalization or intensive outpatient program.  These are paid on a reasonable cost basis.   270.2 - Outpatient Mental Health Payment Limitation for CSW Services  (Rev. 1, 10- 03-03)  The CSW services are subject to the outpatient mental health services limitation in 1833 of the Act.  The imitation of 62.5 percent is applied to the lesser of the actual charge or fee schedule amount.  Diagnostic services are not subject to the limitation.   270.3 - Coinsurance and Deductible for CSW Services  (Rev. 1, 10- 03-03)  The annual Part B deductible and the 20 percent coinsurance apply to CSW services.  280 - Hospital -Based Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing for Non RHC/FQHC Services  (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  A-01-93, A -03-066  Hospitals sometimes operate hospital based RHCs or FQHCs.  Prior to implementation of outpatient PPS, hospital based RHCs/FQHCs were permitted to include both RHC/FQHC and non- RHC/FQHC services on the same claim, under the RHC/FQHC bill type, with appropri ate revenue codes.   Beginning with the implementation of OPPS, non- RHC/FQHC services provided by the hospital based RHC/FQHC, including RHCs/FQHCs that are parts of CAHs or other exempted or excluded (from OPPS) hospitals, must be billed under the host hospitals provider num ber, using hospital billing procedures and bill types.  These services are not covered or paid as RHC/FQHC services but instead may be covered hospital outpatient services and paid under the applicable methodology for the hospital.  The RHC/FQHC services remain subject to the encounter rate payment methodology and are billed using the RHC/FQHC provider number, bill type and revenue codes. See the Medicare Benefit Policy Manual for a description of covered RHC/FQHC services.   See chapter 9, in this manual for billing instructions for provider based and independent RHC/FQHC services.   290 - Outpatient Observation Services  (Rev. 1, 10- 03-03) A3-3663, A3- 3112.8.D, A -01-91  290.1 - Observation Services Overview  (Rev. 1760, Issued:  06- 23-09; Effective Date:  07 -01-09; Implementation Date:  07-06-09)