CMS Pub. 100-04, ch. 4, § 261.1

Hospitals, Community Mental Health Centers, and Critical Access

Hospitals

(Rev. 12423; Issued: 12-20-23; Effective: 01-01-24; Implementation: 01-02-24)

Medicare Part B coverage is available for hospital outpatient intensive outpatient program

services.

A. Billing Requirement

Section 1861 (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm) of the Act

defines the services under the intensive outpatient program benefit in a hospital.

Section 1866(e)(2) of the Act

(http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm) recognizes CMHCs as

“providers of services” but only for furnishing intensive outpatient program and partial

hospitalization services. See §261.1.1 of this chapter for CMHC intensive outpatient

program bill review directions.

Hospitals and CAHs report condition code “92” in FLs 18-28 (or electronic equivalent) to

indicate the claim is for intensive outpatient program services. They must also report a

revenue code and the charge for each individual covered service furnished. In addition,

hospital outpatient departments are required to report HCPCS codes. CAHs are not

required to report HCPCS code for this benefit.

Under component billing, hospitals are required to report a revenue code and the charge

for each individual covered service furnished under an intensive outpatient program. In

addition, hospital outpatient departments are required to report HCPCS codes.

Component billing assures that only those intensive outpatient program services covered

under §1861(ff) of the Act are paid by the Medicare program.

Effective January 1, 2024, for intensive outpatient program services, non-excepted off-campus provider-based departments of a hospital are required to report a “PN” modifier

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 the PN

modifier 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.

Effective January 1, 2024, for intensive outpatient program services, excepted off-campus

provider-based departments of a hospital must continue to report existing modifier “PO”

(Services, procedures, and/or surgeries provided at off-campus provider-based outpatient

departments) for all excepted items and services furnished.

All hospitals are required to report condition code “92” in FLs 18-28 to indicate the claim

is for intensive outpatient program services. Hospitals use bill type 013X and CAHs use

bill type 085X. The following special procedures apply.

Bills must contain an acceptable revenue code. They are as follows:

Revenue

Code

Description

0250 Drugs and Biologicals

043X Occupational Therapy

0900 Behavioral Health Treatment/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

Hospitals other than CAHs are also required to report appropriate HCPCS codes as

follows:

Revenue

Code

Description HCPCS Code

043X Occupational Therapy *G0129 (PHP/IOP)

0900 Behavioral Health

Treatment/Services

****90791 or *****

90792, 97153, 97154,

97155, 97156, 97157,

97158

0904 Activity Therapy **G0176 (PHP/IOP)

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

Revenue

Code

Description HCPCS Code

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 (A) will edit to assure that HCPCS are present when the above revenue

codes are billed and that they are valid HCPCS codes. The A/B MAC (A) will not edit

for matching the revenue code to HCPCS.

*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.

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

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 practitioners

(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 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, the

physician and not the hospital would be responsible for billing 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 payment for the services to the hospital.

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 date 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 Intensive 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

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.