evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(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
(Medicare Claims Processing Manual)
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).
(Medicare Claims Processing Manual)
*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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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)).
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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