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Intensive outpatient program (IOP) billing requirements for institutional services
Last Modified: 5/15/2024
Location: FL, PR, USVI
Business: Part A
The Consolidated Appropriations Act of 2023 (CAA, 2023) established Medicare coverage and payment for IOP services for individuals with mental health needs provided in hospital outpatient departments (HOPD), Critical Access Hospital (CAH) outpatient departments, Community Mental Health Centers (CMHC), Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs). This law establishes the new benefit for services provided on or after January 1, 2024.
IOP is a distinct and organized outpatient program of psychiatric services provided for individuals who have an acute mental illness including conditions such as depression, schizophrenia, and substance use disorders, consisting of a specified group of behavioral health services paid on a per diem basis under the OPPS or other applicable payment system.
IOP services may be furnished in HOPDs, CMHCs, CAH outpatient departments. FQHC and RHCs. IOP services may also be furnished in Opioid Treatment Programs (OTPs) for the treatment of opioid use disorder (OUD).
Effective January 1, 2024, across all these settings, IOP services are available for both individuals with mental health conditions and individuals with substance use disorders. These policies promote access to needed behavioral health care and significantly further CMS' efforts to address the country's behavioral health crisis, as outlined in the
CMS Behavioral Health Strategy 
.
CMS established two IOP Ambulatory Payment Classifications (APCs) for each provider type: one for days with three services per day and one for days with four or more services per day.
HOPDs, CAHs and CMHCs should bill IOP services with the following TOBs:
• Outpatient hospital Part B bills (TOB 13X)
• CAH bills (TOB 85X)
• CMHC bills (TOB 76X)
Outpatient hospital
TOB |
Definition |
131 |
Admit through discharge |
132 |
Interim – First |
133 |
Interim – Continuing |
134 |
Interim – Last |
CAH
TOB |
Definition |
851 |
Admit through discharge |
852 |
Interim – First |
853 |
Interim – Continuing |
854 |
Interim – Last |
CMHC
TOB |
Definition |
761 |
Admit through discharge |
762 |
Interim – First |
763 |
Interim – Continuing |
764 |
Interim – Last |
IOP claims must be submitted in sequence for a continuing course of treatment.
• If a patient completes their course of treatment in the same month, submit your claim with TOB for admission through discharge (131, 851, or 761).
• If the patient does not complete their course of treatment in the same month, submit your claim using the TOB for first interim claim (132, 852, or 762).
• If the patient does not complete their course of treatment in the subsequent month, submit your claim using the TOB for continuing claim (133, 853, or 763).
• Use the continuing claim TOB until the last month of treatment. Submit the last month of treatment with TOB 134, 854 or 764.
Medicare systems will enforce consistency editing for interim billing of claims for IOP services.
Condition codes
IOP services are identified using condition code 92 on claims.
Note: IOP services paid with the OPPS payment methodology are identified as OPPS hospitals on TOB 13X with condition code of 92 or CMHCs on a bill type 076x with a condition code of 92.
When a hospital provides non-IOP mental health services to an IOP patient, all IOP and non-IOP mental health services should be reported on the same hospital claim with condition code 92.
IOP claims with condition code 92 and a separate PHP claim with or without condition code 41 for overlapping periods of time (within seven days of each other) will return to provider (RTP) with reason code 38363.
Revenue codes
Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under an IOP. In addition, HOPDs are required to report Healthcare Common Procedure Coding System (HCPCS) or CPT codes. Component billing assures only those IOP services covered under §1861(ff) of the Act are paid by the Medicare program.
Hospitals, including CAHs and CMHCs must report a revenue code and charge for each individual covered service furnished.
Revenue code |
Description |
0250* |
Drugs & biologicals |
043x |
Occupational therapy |
0900 |
Behavioral health treatment services |
0904 |
Activity therapy |
0905 |
Intensive Outpatient Services-Psychiatric |
0906 |
Intensive Outpatient Services-Chemical Dependency (OTP) |
0914 |
Individual therapy |
0915 |
Group therapy |
0916 |
Family therapy |
0918 |
Behavioral health and testing |
0942 |
Education and training |
• * Revenue code 0250 does not require HCPCS or CPT coding. However, drugs that can be self-administered are not covered by Medicare.
HCPCS and CPT coding
Hospitals (other than CAHs) and CMHCs are required to report appropriate HCPCS and CPT codes.
Revenue Code |
Description |
HCPCS and CPT Codes |
043X |
Occupational Therapy |
*G0129 (PHP/IOP) |
0900 |
Behavioral Health Treatment and Services |
****90791 or *****90792, 97153, 97154, 97155, 97156, 97157, 97158 |
0904 |
Activity Therapy |
**G0176 (PHP/IOP) |
0905 |
Intensive Outpatient Services-Psychiatric |
*G0129, **G0176, ***G0177, G0410, G0411, 90832, 90834, 90837, 90839, 90845, 90846, 90847, 90849, 90853, 90880, 90899, 96112, 96116, 96130, 96132, 96136, 96138 (Not an all-inclusive list) |
0906 |
Intensive Outpatient Services-Chemical Dependency (OTP) |
(Not yet defined) |
0914 |
Individual Psychotherapy |
90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90865, 90880, 90899 |
0915 |
Group Therapy |
G0410, G0411, 90853 |
0916 |
Family Psychotherapy |
90846, 90847, 90849 |
0918 |
Behavioral Health and Testing |
96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96161, 96164, 96167, 97151, 97152 |
0942 |
Education and Training |
G0023, G0024, G0140, G0146, ***G0177, G0451, 96202, 96203, 97550, 97551, 97552 |
• *The definition of code G0129 is as follows:
• Occupational therapy services requiring 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 problems, per session (45 minutes or more).
• ***The definition of code G0177 is as follows:
• 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:
• diagnostic evaluation (no medical services) completed by a nonphysician.
• *****The definition of code 90792 is as follows:
• diagnostic evaluation (with medical services) completed by a physician.
• HCPCS codes G0129 and G0176 are only used for IOP or PHP.
• HCPCS code G0177 may be used in IOPs, PHPs, and outpatient mental health settings.
Editing will occur to ensure HCPCS or CPT codes are present and valid when the revenue codes above are billed. Claims will not edit for the matching of the revenue code to the HCPCS or CPT code.
Modifier PN
IOP services provided in non-excepted off-campus provider-based departments of a hospital are required to report modifier "PN" on each claim line for non-excepted items and services. The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule. We expect modifier PN to be reported with each non-excepted item and service, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.
Modifier PO
IOP services provided in excepted off-campus provider-based departments of a hospital must continue to report existing modifier "PO" (Services, procedures and surgeries provided at off-campus provider-based outpatient departments) for all excepted items and services furnished.
Hospitals report the number of times the service or procedure, as defined by the HCPCS or CPT code, was performed. CAHs report the number of times the revenue code visit was performed.
When reporting service units for HCPCS or CPT 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.
Hospital example:
A beneficiary received psychological testing (HCPCS or CPT code 96100 which is defined in one-hour intervals) for a total of three hours for one day. The hospital reports revenue code 0905 in FL 42, HCPCS or CPT code 96100 in FL 44, and three units in FL 46. The CAH would report revenue code 0918, leave HCPCS or CPT blank, and report one unit in FL 46.
For CMHCs, in the "Service Units" field, report the number of times the service or procedure, as defined by the HCPCS or CPT code, was performed when billing for IOP services identified by the revenue code.
Service units are not required for drugs and biologicals (revenue code 0250).
CMHC example:
A beneficiary received psychological testing performed by a physician for a total of three hours for one day (HCPCS or CPT code 96130, first hour; HCPCS or CPT code 96131 for 2 additional hours). The CMHC reports revenue code 0905, HCPCS or CPT code 96130, and 1 unit; and a second line on the claim showing revenue code 0905, HCPCS or CPT code 96131, and 2 units. When reporting service units for HCPCS or CPT 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.
Hospitals, other than CAHs and CMHCs, are required to report line-item dates of service (LIDOS) on each revenue code line. Each service (revenue code) provided must be repeated on a separate line-item along with the specific date of service (DOS) for each occurrence. Line-item dates of service are reported in FL 45 "Service Date" (MMDDYY).
For CMHCs, report DOS per revenue code line for claims spanning 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 FL 45 "Service Date".
CMHC example for group therapy services provided twice during a billing period:
Revenue Code |
HCPCS |
DOS |
Units |
Total Charges |
0905 |
G0176 |
05052024 |
1 |
$80.00 |
0905 |
G0176 |
05292024 |
2 |
$160.00 |
The patient status should be 30 (still a patient) for IOP services billed on a TOB XX2 and XX3.
Patients in IOP may be discharged by either stepping down to a less intensive level of outpatient care when the patient's clinical condition improves or stabilizes and the patient no longer requires structured, intensive, multimodal treatment, or by stepping up to a more intensive level of care. This could include PHP or inpatient level of care (which would be required for patients needing 24-hour supervision).
When the patient is discharged from IOP, be sure to complete the patient status appropriately.
Value |
Description |
01 |
Discharged to home or self-care (routine discharge) |
02 |
Discharged or transferred to a short-term general hospital for inpatient care |
03 |
Discharged or transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care |
04 |
Discharged or transferred to a facility providing custodial or supportive care (intermediate care facility [ICF]) |
05 |
Discharged or transferred to another type of institution |
06 |
Discharged or transferred to home under care of organized home health service organization |
07 |
Left against medical advice or discontinued care |
09 |
Discharged from outpatient care to be admitted to this same hospital which the patient received outpatient services |
20 |
Expired (or did not recover – Christian Science Patient) |
21 |
Discharged and transferred to court or law enforcement |
30 |
Still a patient |
41 |
Expired in a medical facility, i.e., hospital, SNF, ICF or freestanding hospice |
43 |
Discharged or transferred to federal health care facility |
50 |
Hospice – home |
51 |
Hospice – medical facility providing hospice level of care |
61 |
Discharged or transferred to a hospital-based Medicare approved swing bed |
62 |
Discharged or transferred to inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital |
63 |
Discharged or transferred to a Medicare-certified long term care hospital (LTCH) |
64 |
Discharged or transferred to a nursing facility certified under Medicaid but not certified under Medicare. |
65 |
Discharged or transferred to a psychiatric hospital or psychiatric distinct part of a hospital (effective for discharges on or after April 1, 2004). |
66 |
Discharged or transferred to a CAH |
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for current discharge status codes.
