Intensive Outpatient Services

70.4 - Intensive Outpatient Services (Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24) Intensive outpatient programs (IOPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in §1861(ff) of the Social Security Act (the Act). An IOP furnishes treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation, but less intense than a PHP. Programs providing primarily social, recreational, or diversionary activities are not considered intensive outpatient programs. A. Program Criteria IOPs work best as part of a community continuum of mental health services (including SUD services) which range from the most restrictive inpatient hospital setting to less restrictive outpatient care and support. Program objectives should focus on ensuring important community ties and closely resemble the real-life experiences of the patients served. IOPs may be covered under Medicare when they are provided by a hospital outpatient department, a Medicare-certified CMHC, a rural health clinic (RHC), a Federally qualified health center (FQHC), or an Opioid Treatment Program (OTP). See chapter 13 in this manual for RHCs and FQHCs; see chapter 17 in this manual for OTPs. An IOP is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, directly related to the reason for admission to the program, and medically necessary. A program comprised primarily of diversionary activity, social, or recreational therapy does not constitute an IOP. Psychosocial programs which provide only a structured environment, socialization, and/or vocational rehabilitation are not covered by Medicare. A program that only monitors the management of medication for patients whose psychiatric condition is otherwise stable, is not the combination, structure, and intensity of services which make up active treatment in an IOP. B. Patient Eligibility Criteria 1. Benefit Category Patients must meet benefit requirements for receiving the intensive outpatient services as defined in §1861(ff) of the Act. Patients admitted to an IOP must be under the care of a physician who certifies the need for intensive outpatient services, including the need for a minimum of 9 hours per week of services, as evidenced by their plan of care. The patients also require a comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder (including SUD) which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning. Such dysfunction generally is of an acute nature. In addition, IOP patients must be able to cognitively and emotionally participate in the active treatment process and be capable of tolerating the intensity of an IOP program. Generally speaking, an IOP is less intensive than a PHP. For patients of an IOP, section 1835(a)(2)(F)(i) of the Act does not apply, that is, individuals receiving IOP do not require inpatient psychiatric care in the absence of such services. Patients meeting benefit category requirements for Medicare coverage of an IOP are those who need more intensive treatment than that provided by outpatient services, but who need less intensive treatment than that provided by a PHP. There must be evidence of the need for the acute, intense, structured combination of services provided by an IOP. Recertification must address the continuing serious nature of the patients’ psychiatric condition requiring active treatment in an IOP. Discharge planning from an IOP may reflect the types of best practices recognized by professional and advocacy organizations that ensure coordination of needed services and follow-up care. These activities include linkages with community resources, supports, and providers in order to promote a patient’s return to a higher level of functioning in the least restrictive environment. 2. Covered Services Items and services that can be included as part of the structured, multimodal active treatment program, identified in §1861(ff)(2) include: • Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, mental health counselors, marriage and family therapists, clinical nurse specialists, certified alcohol and drug counselors); • Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physician’s treatment plan for the individual; • Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients (including patients with SUD). These include principal illness navigation services provided by auxiliary staff, including peer support specialists; • Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29); • Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals; • Family counseling services for which the primary purpose is the treatment of the patient’s condition. These include counseling services for caregivers; • Patient training and education, to the extent the training and educational activities are closely and clearly related to the individual’s care and treatment of his/her diagnosed psychiatric condition. These services include caregiver training services furnished for the benefit of the patient; and • Medically necessary diagnostic services related to mental health treatment (including SUD). Intensive outpatient services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial. It is the need for at least 9 hours per week of intensive, active treatment of the patient's condition to maintain a functional level that qualifies the patient to receive the services identified in §1861(ff). 3. Reasonable and Necessary Services This program of services provides for the diagnosis and active, intensive treatment of the individual’s serious psychiatric condition (including SUD) and, in combination, are reasonably expected to improve or maintain the individual’s condition and functional level. A particular individual covered service (described above) as intervention, expected to maintain or improve the individual’s condition and prevent relapse or hospitalization, may also be included within the plan of care, but the overall intent of the intensive outpatient program is to treat the serious presenting psychiatric symptoms (including SUD). Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent relapse or hospitalization. Patients admitted to an IOP do not require 24-hour per day supervision as provided in an inpatient setting, must have an adequate support system to sustain/maintain themselves outside the IOP, and must not be an imminent danger to themselves or others. Patients admitted to an IOP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5, of the version of the International Classification of Diseases (ICD) applicable to the service date, which severely interferes with multiple areas of daily life. Examples include eating disorders, mood disorders, psychotic disorders, and substance use disorders. The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients require the level of treatment provided in an inpatient setting, and not so limiting that patients cannot benefit from participating in an active treatment program. Additionally, patients in an IOP will generally require fewer hours of services per week than patients participating in a PHP. It is the need, as certified by the treating physician, for the intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patient’s presenting psychiatric condition (including SUD). For patients who do not meet this degree of severity of illness, and for whom an intensive outpatient program is not necessary for the treatment of a psychiatric condition (including SUD), professional services billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even though an intensive outpatient program is not. 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 a PHP or an inpatient level of care (which would be required for patients needing 24-hour supervision). b. Reasons for Denial a. Benefit category denials made under §1861(ff) are not appealable by the provider and the limitation on liability provision does not apply (HCFA Ruling 97-1). Examples of benefit category based in §1861(ff) of the Act for intensive outpatient program services generally include the following: o Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care; o Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or o Patients who are otherwise psychiatrically stable or require medication management only. b. Coverage denials made under §1861(ff) of the Act are not appealable by the provider and the Limitation on Liability provision does not apply (HCFA Ruling 97- 1). The following services are excluded from the scope of intensive outpatient services defined in §1861(ff) of the Social Security Act: • Services to hospital inpatients; • Meals, self-administered medications, transportation; and • Vocational training. c. Reasonable and necessary denials based on §1862(a)(1)(A) are appealable and the Limitation on Liability provision does apply. The following examples represent reasonable and necessary denials for intensive outpatient program services and coverage is excluded under §1862(a)(1)(A) of the Social Security Act: • Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of an IOP; or • Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization. b. Documentation Requirements and Physician Supervision The following components will be used to help determine whether the services provided were accurate and appropriate. b. Initial Psychiatric Evaluation/Certification.--Upon admission, certification by the physician must be made that the patient admitted to the IOP requires a minimum of 9 hours of services per week. The certification should identify the diagnosis and clinical need for the intensive outpatient program. Intensive outpatient services must be furnished under an individualized written plan of care, established by the physician, which includes the active treatment provided through the combination of structured, intensive services identified in § 1861 that are reasonable and necessary to treat the presentation of serious psychiatric symptoms (including SUD) and to prevent relapse or hospitalization. b. Physician Recertification Requirements.-- • Signature – The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient’s response to treatment. • Timing – Recertifications are required at intervals established by the provider, but no less frequently than every 60 days following the initial IOP certification. • Content – The recertification must specify that the patient requires a minimum of 9 hours of mental health treatment services per week and describe the following: • The patient’s response to the therapeutic interventions provided by the IOP; • The patient’s psychiatric symptoms (including SUD) that continue to require intensive treatment; and • Treatment goals for coordination of services to facilitate discharge from the IOP. c. Treatment Plan.--An intensive outpatient program is active treatment pursuant to an individualized treatment plan, prescribed and signed by a physician, which identifies treatment goals, describes a coordination of services, is structured to meet the particular needs of the patient, and includes a multidisciplinary team approach to patient care. The treatment goals described in the treatment plan should directly address the presenting symptoms and are the basis for evaluating the patient’s response to treatment. Treatment goals should be designed to measure the patient’s response to active treatment. The plan should document ongoing efforts to restore the individual patient to a higher level of functioning that would permit discharge from the program, or reflect the continued need for the intensity of the active therapy to maintain the individual’s condition and functional level and to prevent relapse or hospitalization. Activities that are primarily recreational and diversionary, or provide only a level of functional support that does not treat the serious presenting psychiatric symptoms (including SUD) placing the patient at risk, do not qualify as intensive outpatient program services. d. Progress Notes.--Section 1833(e) of the Social Security Act prevents Medicare from paying for services unless necessary and sufficient information is submitted that shows that services were provided and to determine the amounts due. A provider may submit progress notes to document the services that have been provided. The progress note should include a description of the nature of the treatment service, the patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan. See the Medicare Claims Processing Manual, Chapter 4, “Hospital Outpatient Services,” §261 for billing instructions for intensive outpatient program services.