CMS Pub. 100-04, ch. 4, § 261.1.1

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

1400–1499, 4600–4799, and 4900–4999.

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

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

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

Revenue

Codes

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(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).

**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 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 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 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 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 the 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

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 second 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:

Revenu

e Code

HCPC

S

Dates of

Service

Unit

s

Total

Charge

s

0915 G0410 2024050

5

1 $80

0915 G0410 2024052

9

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)).

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.