evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
1. Benefit Category    Patients must meet benefit requirements for receiving the intensive outpatient services as defined in 1861(ff) of the Act.  Patients admitted to an IOP must be under the care of a physician who certifies the need for intensive outpatient services, includi ng the need for a minimum of 9 hours per week of services, as evidenced by their plan of care.  The patients also require a comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder (including SUD) which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning.  Such dysfunction generally is of an acute nature.  In addition, IOP patients  must be able to cognitively and emotionally participate in the active treatment process and be capable of tolerating the intensity of an IOP program.    Generally speaking, an IOP is less intensive than a PHP. For patients of an IOP, section 1835(a)(2)(F)(i) of the Act does not apply, that is, individuals receiving IOP do not require inpatient psychiatric care in the absence of such services.  Patients meeting benefit category requirements for Medicare coverage of an IOP are those who need more intensive treatment than that provided by outpatient services, but who need less intensive treatment than that provided by a PHP.  There must be evidence  of the need for the acute, intense, structured combination of services provided by an IOP.  Recertification must address the continuing serious nature of the patients psychiatric condition requiring active treatment in an IOP.    Discharge planning from an IOP may reflect the types of best practices recognized by professional and advocacy organizations that ensure coordination of needed services and follow -up care.  These activities include linkages with community resources, suppor ts, and providers in order to promote a patients return to a higher level of functioning in the least restrictive environment.    2. Covered Services     Items and services that can be included as part of the structured, multimodal active treatment program, identified in 1861(ff)(2) include:     Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, mental health counselors, marriage and family therapists, clinical nurse specialists, certified alcohol and drug counselors);
(Medicare Benefit Policy Manual)
 Occupational therapy requiring the skills of a qualified occupational therapist.  Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;     Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients (including patients with SUD). These include principal illness navigation services provided by auxiliary staff, including peer support specialists;     Drugs and biologicals that cannot be self -administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);     Individualized activity therapies that are not primarily recreational or diversionary.  These activities must be individualized and essential for the treatment of the patients diagnosed condition and for progress toward treatment goals;     Family counseling services for which the primary purpose is the treatment of the patients condition. These include counseling services for caregivers;     Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition. These services include caregiver training services furnished for the benefit of the patient; and     Medically necessary diagnostic services related to mental health treatment (including SUD).   Intensive outpatient services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial.  It is the need for at least 9 hours per week of  intensive, active treatment of the patient's condition to maintain a functional level that  qualifies the patient to receive the services identified in 1861(ff).    3. Reasonable and Necessary Services
(Medicare Benefit Policy Manual)
3. Reasonable and Necessary Services    This program of services provides for the diagnosis and active, intensive treatment of the individuals serious psychiatric condition (including SUD) and, in combination, are reasonably expected to improve or maintain the individuals condition and functio nal level.  A particular individual covered service (described above) as intervention, expected to maintain or improve the individuals condition and prevent relapse or hospitalization, may also be included within the plan of care, but the overall intent of the intensive outpatient program is to treat the serious presenting psychiatric symptoms (including SUD).  Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent relapse or hospitalization.    Patients admitted to an IOP do not require 24- hour per day supervision as provided in an inpatient setting, must have an adequate support system to sustain/maintain themselves outside the IOP, and must not be an imminent danger to themselves or others.  Patients admitted to an IOP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter  5, of the version of the International Classification of Diseases (ICD) applicable to the service date, which severely interferes with multiple areas of daily life.  Examples include eating disorders, mood disorders, psychotic disorders, and substance use  disorders.   The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients require the level of treatment provided in an inpatient setting, and not so limiting that patients c annot benefit from participating in an active treatment program.  Additionally, patients in an IOP will generally require fewer hours of services per week than patients participating in a PHP. It is the need, as certified by the treating physician, for the  intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patients presenting psychiatric condition (including SUD).
(Medicare Benefit Policy Manual)
For patients who do not meet this degree of severity of illness, and for whom an intensive outpatient program is not necessary for the treatment of a psychiatric condition (including SUD), professional services billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even though an intensive outpatient program is not.    Patients in IOP may be discharged by either stepping down to a less intensive level of outpatient care when the patients clinical condition improves or stabilizes and the patient no longer requires structured, intensive, multimodal treatment, or by steppi ng up to a more intensive level of care. This could include a PHP or an inpatient level of care (which would be required for patients needing 24- hour supervision).    b. Reasons for Denial    a. Benefit category denials made under 1861(ff) are not appealable by the provider and the limitation on liability provision does not apply (HCFA Ruling 97-1).  Examples of benefit category based in 1861(ff) of the Act for intensive outpatient program servi ces generally include the following:   o Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;   o Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or    o Patients who are otherwise psychiatrically stable or require medication management only.     b. Coverage denials made under 1861(ff) of the Act are not appealable by the  provider and the Limitation on Liability provision does not apply (HCFA Ruling 97-1).  The following services are excluded from the scope of intensive outpatient services defined in 1861(ff) of the Social Security Act:     Services to hospital inpatients;   Meals, self -administered medications, transportation; and   Vocational training.    c. Reasonable and necessary denials based on 1862(a)(1)(A) are appealable and the Limitation on Liability provision does apply.  The following examples represent reasonable and necessary denials for intensive outpatient program services and coverage is exclu ded under 1862(a)(1)(A) of the Social Security Act:
(Medicare Benefit Policy Manual)
 Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of an IOP; or      Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.     b. Documentation Requirements and Physician Supervision    The following components will be used to help determine whether the services provided were accurate and appropriate.    b. Initial Psychiatric Evaluation/Certification .--Upon admission, certification by the physician must be made that the patient admitted to the IOP requires a minimum of 9 hours of services per week.  The certification should identify the diagnosis and clinical need for the intensive outpatient program.  Intensive outpatient services must be furnished under an individualized written plan of care, established by the physician, which includes the active treatment provided through the combination of structured, intensive services identified in  1861 that are reasonable and necessary to treat the presentation of serious psychiatric symptoms (including SUD) and to prevent relapse or hospitalization.    b. Physician Recertification Requirements .--     Signature  The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patients response to treatment.     Timing  Recertifications are required at intervals established by the provider, but no less frequently than every 60 days following the initial IOP certification.      Content  The recertification must specify that the patient requires a minimum of 9 hours of mental health treatment services per week and describe the following:      The patients response to the therapeutic interventions provided by the IOP;     The patients psychiatric symptoms (including SUD) that continue to require intensive treatment; and     Treatment goals for coordination of services to facilitate discharge from the IOP.
(Medicare Benefit Policy Manual)
 The patients response to the therapeutic interventions provided by the IOP;     The patients psychiatric symptoms (including SUD) that continue to require intensive treatment; and     Treatment goals for coordination of services to facilitate discharge from the IOP.     c. Treatment Plan.--An intensive outpatient program is active treatment pursuant to an individualized treatment plan, prescribed and signed by a physician, which identifies treatment goals, describes a coordination of services, is structured to meet the particular needs of the patient, and includes a multidisciplinary team approach to patient care.  The treatment goals described in the treatment plan should directly address the presenting symptoms and are the basis for evaluating the patients response to treatment.  Treatment goals should be designed to measure the patients response to active treatment.  The plan should document ongoing efforts to restore the individual patient to a higher level of functioning that would permit discharge from the program, or reflect the continued need for the intensity of the active therapy to maintain the individuals condition and functional level and to prevent relapse or hospitalization.  Activities that are primarily recreational and diversionary, or provide only a level of functional support that does not treat the serious presenting psychiatric symptoms (including SUD) placing the patient at risk, do not qualify as intensive outpatient program services.    d. Progress Notes.--Section 1833(e) of the Social Security Act prevents Medicare from paying for services unless necessary and sufficient information is submitted that shows that services were provided and to determine the amounts due.  A provider may submit progress notes to document the services that have been provided.  The progress note should include a description of the nature of the treatment service, the patients response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.    See the Medicare Claims Processing Manual, Chapter 4, Hospital Outpatient Services, 261 for billing instructions for intensive outpatient program services.  70.5 - Laboratory Services Furnished to Nonhospital Patients by Hospital Laboratory  (Rev. 82; Issued:  02-08- 08; Effective:  01 -01-08; Implementation:  03 -10-08)
(Medicare Benefit Policy Manual)
A nonhospital patient is an individual who is neither an inpatient nor outpatient of the hospital furnishing the service.  (See the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 1, Inpatient Hospital Services, section 10, for the definition of a hospital inpatient and section 20.1 for the definition of a hospital outpatient).  Nonhospital patients primarily are individuals from whom a specimen had been taken and sent to the hospital for analysis and the patient does not receive hospital outpatient services on the same day.  For all hospitals except CAHs and Maryland waiver hospitals, if a beneficiary receives hospital outpatient services on the same day as a specimen collection and laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non-patient on that day for purposes of the specimen collection and laboratory test.  However if the non-CAH or Maryland waiver hospital only collects or draws a specimen from the beneficiary and the bene ficiary does not also receive hospital outpatient services on that day, the hospital may choose to register the beneficiary as an outpatient for the specimen collection or bill for these services as non- patient on the 14X bill type.  For CAHs, payment for clinical diagnostic laboratory tests is made at 101 percent of reasonable cost, only if the individuals are outpatients of the CAH, as defined in 42 CFR 410.2, and are physically present in the CAH at the time the specimens are collec ted.  Clinical diagnostic laboratory tests performed for persons who are not physically present (non- patients) at the CAH when the specimens are collected are made in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Social Security Act.  See also 42 CFR 413.70(b)(iii).  Similarly, for Maryland waiver hospitals, the waiver is limited to services to inpatients and registered outpatients as defined in 42 CFR 410.2.  Therefore payment for non -patients (specimen only, TOB 14X) who are not registered outpatients at the time of specimen collection will be made on the clinical diagnostic laboratory fee schedule.  Such services are covered to the extent appropriate.
(Medicare Benefit Policy Manual)
See the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 16, Laboratory Services from Independent Labs, Physicians, and Providers, section 40.3, for billing and payment of clinical diagnostic laboratory services for patients and non- patients.   80 - Rental and Purchase of Durable Medical Equipment  (Rev. 1, 10- 01-03) A3-3113, HO -235, HHA -220  Rental and purchase of DME is covered under Part B for use in a patients home. DME rendered to inpatients of a SNF or hospital is covered as part of the prospective payment system and not separately payable.  See the Medicare Benefit Policy Manual, Chapter 15, 110 for coverage of Durable Medical Equipment and the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), for special billing i nstructions.  90 - Services of Interns And Residents  (Rev. 1, 10- 01-03) A3-3115, HO -237  A.  General   For Medicare purposes, the terms interns and residents include physicians participating in approved postgraduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital setting, e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools.  Where a senior resident has a staff or faculty appointment or is designated, for example, a fellow, it does not  change the residents status for the purposes of Medicare coverage and reimbursement.  As a general rule, services of interns and residents are paid as provider services by the A/B MAC (A) .  B.  Services Furnished by Interns and Residents Within the Scope of an Approved Training Program
(Medicare Benefit Policy Manual)
B.  Services Furnished by Interns and Residents Within the Scope of an Approved Training Program   Medical and surgical services furnished by interns and residents within the scope of their training program are covered as provider services.  Effective with services furnished on or after July 1, 1987, this includes services furnished in a setting which i s not part of the provider where a hospital has agreed to incur all or substantially all of the costs of training in the nonprovider facility.  Providers are required to notify the A/B MAC (B) of such agreements.  Where the provider does not incur all or s ubstantially all of the training costs and the services are performed by a licensed physician, the services are reimbursable on a reasonable charge basis by the A/B MAC (B).  Prior to July 1, 1987, the covered services of interns and residents were reimbur sed by the A/B MAC (B) on a reasonable charge basis as physician services if furnished by a licensed physician off the provider premises regardless of who incurred the training costs.  C.  Services Furnished by Interns and Residents Outside the Scope of an Approved Training Program -  Moonlighting   Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed outside the facility where they have their training program, are covered as physicians services and paid on a reasonable cha rge basis where the requirements in 1 and 2, below, are met.  Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed in an outpatient department or emergency room of the hospital w here they have their training program, are covered as physicians services and paid on a reasonable charge basis where the following criteria are met:   1. The services are identifiable physicians services, the nature of which requires performance by a physician in person and which contributes to the diagnosis or treatment of the patients condition;   2. The intern or resident is fully licensed to practice medicine, osteopathy, dentistry or podiatry by the State in which the services are performed; and   3. The services performed can be separately identified from those services that are required as part of the training program.  When these criteria are met, the services are considered to have been furnished by the individuals in their capacity as physicians and not in their capacity as interns and residents.
(Medicare Benefit Policy Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12421BP  12/21/2023 January 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/02/2024 13488  R12425BP  12/21/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update 01/02/2024 13496  R10541BP  12/31/2020 January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS  01/04/2021 12020  R267BP  02/04/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/06/2020 11605  R266BP  01/15/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) - No Longer Sensitive/Controversial  Rescinded and Replaced by Transmittal 267 01/15/2020 11605
(Medicare Benefit Policy Manual)
12/20/2019 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) -SENSITIVE/CONTROVERSIAL  01/06/2020 11605  R215BP  12/18/2015 January 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/04/2016 9486 R194BP  09/03/2014 Pub. 100-02 Language-Only Update for ICD-10 Upon Implementation of ICD -10 8605 R182BP  03/21/1014 Implementing the Part B Inpatient Payment Policies from CMS -1599-F 04/21/2014 8666 R181BP  03/14/2014 Pub. 100-02 Language-Only Update for ICD-10  Rescinded and replaced by Transmittal 194  10/01/2014 8605 R169BP  03/01/2013 April 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS)  04/01/2013 8228 R157BP  06-08-2012 July 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/02/2012 7847 R152BP  12/29/2011 January 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2012 7672 R143BP  04/29/2011 Manual Restructuring of Chapter 6, Section 20, Subsections 20.4.4 and 20.5.2 05/31/2011 7354 R137BP  12/30/2010 January 2011 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2011 7271 R128BP  05/28/2010 July 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/06/2010 6996 R116BP  12/11/2009 January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/04/2010 6751 R107BP  05/22/2009 July 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/06/2009 6492 R101BP  01/16/2009 January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/05/2009 6320 R100BP  12/31/2008 January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS)
(Medicare Benefit Policy Manual)
January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/05/2009 6320 R100BP  12/31/2008 January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS)  Rescinded and replaced by Transmittal 101  01/05/2009 6320 R90BP  06/19/2008 July Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/07/2008 6094 R82BP  02/08/2008 January 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS) Manualization  03/10/2008 5946 R42BP  12/16/2005 January 2006 Update of the Hospital Outpatient Prospective Payment System (OPPS) Manual Instruction: Changes to Coding and Payment for Observation 01/03/2006 4259 R37BP  08/12/2005 Conforming Changes for Change Request 3648 to Pub. 100-02 09/12/2005 3912 R19BP  09/10/2004 Hospital Services Covered Under Part B 10/12/2004 3444 R10BP  05/07/2004 Chapter 6, Hospital Services Covered Under Part B  N/A 3298 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 8 - Coverage of Extended Care (SNF) Services  Under Hospital Insurance    Table of Contents  (Rev. 12283; Issued: 10-05-23)