Intensive Outpatient Program (IOP) Services

110 - Intensive Outpatient Program (IOP) Services (Rev. 13264, Issued:06-09-25; Effective: 06-02-25; Implementation: 06-02-25) Effective January 1, 2024, section 4124 of the Consolidated Appropriations Act of 2023 (CAA, 2023) establishes Medicare coverage and payment for Intensive Outpatient Program (IOP) services for individuals with mental health needs when furnished by hospital outpatient departments, Community Mental Health Centers (CMHCs), Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs). Section 4124(c) of the CAA, 2023 requires payment for IOP services furnished by RHCs and FQHCs to be made at the same payment rate as if it were furnished by a hospital. For additional information regarding IOP benefits and services, see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 250. A. Billing Requirements • TOB: 71X (RHC) or 77X (FQHC) • Date of services for 3 or less services: on or after 01/01/24 • Date of services for 4 or more: on or after 01/01/25 • Revenue codes: 0905 or 0519 (MA claim). • Condition code 92. • HCPCS codes listed below for (a) primary services and (b) other services. a. Primary Services: 90832, 90834, 90837, 90845, 90846, 90847, 90853, 90880, 96112, 96116, 96130, 96132, 96136, 96138, G0410, G0411 b. Other Services: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839 ,90840, 90845, 90846, 90847, 90849, 90853, 90880, 90899, 96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96164, 96167, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, G0129, G0176, G0177, G0410, G0411, G0451 c. At least one IOP HCPCS code from the (a) Primary Services above must be included on the claim for payment. Additional IOP services listed on the claim will be bundled for that specific day. • A FQHC payment code and qualifying visit is not required with a IOP visit. • FQHCs must report charges on the primary service line for all IOP services furnished that day to be included in the calculation for coinsurance. • RHCs must also report the CG modifier on the line for payment along with the charges. B. Multiple Visits • Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and a single location constitute a single visit, except when a patient has a medical visit and a mental health visit on the same day or when a patient has an initial preventive physical exam and a separate medical or mental health visit on the same day. Since IOP services are behavioral health services, payment for a mental health visit and IOP services on the same day is allowed but paid a single payment based on the IOP rate. In the case of a medical visit, an encounter can include a medical visit and a mental health visit or a medical visit and IOP services on the same day. However, an encounter cannot include two mental health visits on the same day. Note: Report a line-item date of service per revenue code line for IOP 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. Examples: • IOP services are furnished on the same day as a mental health visit, only one payment will be considered at the IOP rate. That is, payment for the mental health visit will be included under the IOP rate. • IOP services are furnished on the same day as a medical visit, there will be one payment for the medical visit under the FQHC PPS or under the RHC AIR methodology and one payment for IOP services at the IOP rate. Mental health services should continue to be reported with revenue code 0900. Do not report IOP services with revenue code 0900. IOP services should be billed with revenue code 0905. C. FQHC Supplement Payments To receive the wrap-around payment, FQHCs that contract with MA organizations must report condition code 92, revenue code 0519 and a HCPCS code from the Primary List A. Please see section 60.4 of this chapter for additional information on Supplement Payments. D. Payment Payment for Intensive Outpatient (IOP) services provided by Rural Health Clinics (RHCs) will be based on the rate established for hospital-based IOPs, which is the per diem payment amount for three services per day or four or more-day services, rather than the RHC All-Inclusive Rate (AIR). Payment for IOP services furnished in FQHC will be the lesser of a FQHC actual charges or the rate determined for hospital-based IOPs and not the FQHC PPS. Additionally, historically excepted tribal FQHCs will have their payment based on the IHS Medicare outpatient per visit rate when furnishing IOP services. That is, payment is based on the lesser of a historically excepted tribal FQHC actual charges or the IHS Medicare outpatient per visit rate. Coinsurance and deductibles apply to RHC claims, and coinsurance applies to FQHC claims for these services. Only one payment rate is allowed per day for the IOP services.