CMS SOM App. FC, Tag M0366

chapter.

Interpretive Guidelines §485.918(g)(2)

§410.44 Intensive outpatient services: Conditions and exclusions.

a) Intensive outpatient services are services that—

(1) Are reasonable and necessary for the diagnosis or active treatment of the

individual’ s condition;

(2) Are reasonably expected to improve or maintain the individual’ s condition and

functional level and to prevent relapse or hospitalization;

(3) Are furnished in accordance with a physician certification and plan of care as

specified under §424.24(d) of this chapter; and

(4) Include any of the following:

(i) Individual and group therapy with physicians or psychologists or other

mental health professionals (including substance use disorder professionals)

to the extent authorized under State law.

(ii) Occupational therapy requiring the skills of a qualified occupational

therapist, provided by an occupational therapist, or under appropriate

supervision of a qualified occupational therapist by an occupational therapy

assistant as specified in part 484 of this chapter.

(iii) Services of social workers, trained psychiatric nurses, and other staff

trained to work with psychiatric patients (including patients with substance

use disorder).

(iv) Drugs and biologicals furnished for therapeutic purposes, subject to the

limitations specified in §410.29.

(v) Individualized activity therapies that are not primarily recreational or

diversionary.

(vi) Family counseling, the primary purpose of which is treatment of the

individual’ s condition.

(vii) Patient training and education, to the extent the training and

educational activities are closely and clearly related to the individual’ s care

and treatment.

(viii) Diagnostic services.

(b) The following services are separately covered and not paid as intensive outpatient

services:

(1) Physician services that meet the requirements of §415.102(a) of this chapter for

payment on a fee schedule basis.

(2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.

(3) Nurse practitioner and clinical nurse specialist services, as defined in section

1861(s)(2)(K)(ii) of the Act.

(4) Qualified psychologist services, as defined in section 1861(ii) of the Act.

(5) Services furnished to SNF residents as defined in §411.15(p) of this chapter.

(c) Intensive outpatient programs are intended for patients who –

(1) Require a minimum of 9 hours per week of therapeutic services as evidenced in

their plan of care;

(2) Are likely to benefit from a coordinated program of services and require more

than isolated sessions of outpatient treatment;

(3) Do not require 24-hour care;

(4) Have an adequate support system while not actively engaged in the program;

(5) Have a mental health or substance use disorder diagnosis;

(6) Are not judged to be dangerous to self or others; and

(7) Have the cognitive and emotional ability to participate in the active treatment

process and can tolerate the intensity of the intensive outpatient program.