January 2, 2024
Intensive Outpatient Program Services
On or after January 1, 2024, Medicare Part B covers Intensive Outpatient Program (IOP) services for individuals with mental health needs provided in:
- Hospital outpatient departments
- Community Mental Health Centers (CMHCs)
- Critical Access Hospital (CAH) outpatient departments
- Rural Health Clinics (RHCs)
- Federally Qualified Health Centers (FQHCs)
- Opioid Treatment Programs (OTPs)
Hospitals, CMHCs and CAHs
- General Billing Requirements
Claims for IOP services must include the following:- Type of Bill:
- Hospital = TOB 13X
- CMHC = TOB 76X
- CAH = TOB 85X
- Condition Code 92
- Revenue Code (and charge for each individual covered service furnished under an IOP)
- HCPCS Codes (not required for CAHs)
- Modifier PN or PO (when IOP services are furnished in off-campus provider-based departments of a hospital)
- Type of Bill:
- Interim Billing Requirements
Submit daily, weekly or monthly claims as follows:- Sequential Billing
- Submit claims in the same sequence in which the IOP services are furnished.
- You must receive a remittance advice for the prior bill before you submit the next bill.
- TOB Frequency & Patient Discharge Status Codes
TOB Description Patient Discharge Status Code 131, 761 or 851 Admit through Discharge Claim Other than 30 132, 762 or 852 Interim – First Claim 30 (still a patient) 133, 763 or 853 Interim – Continuing Claim 30 (still a patient) 134, 764 or 854 Interim – Last Claim Other than 30
- Sequential Billing
- Additional Guidance
- MM13222 – New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services
- MM13496 – Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1, section 50.2.3
Other Providers
- RHCs/FQHCs – Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 9
- OTPs – Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 39