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Intensive outpatient program (IOP) billing requirements for institutional services

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 services

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 CMS' behavioral health strategy.

The Calendar year (CY) 2024 outpatient prospective payment system (OPPS) ambulatory surgical center (ASC) final rule includes the scope of benefits, physician certification requirements, coding and billing, and payment rates under the IOP benefit.

Guidance for RHCs and FQHCs can be found on their institutional provider page.

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.

Type of bills (TOBs) for institutional billing

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

Sequential billing

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. 

IOP coding 

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 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:

    • Training 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:

    • 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

  • 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 reporting

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 (MPFS). 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.

Reporting service units

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. 

Line-item date of service reporting

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

Patient status

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

Refer to CMS IOM Pub. 100-04 Claims Processing Manual, Chapter 25, section 75.2 for current discharge status codes.

 

References