In substance abuse treatment, there are generally four types of facility-based behavioral health services considered eligible for reimbursement:
- A hospital-based inpatient program offering 24/7 nursing care and medical monitoring as well as appropriate behavioral health services,
- Residential treatment in a sub-acute facility with 24/7 monitoring and active behavioral health services,
- A partial hospital program, or PHP, in which services are provided in an ambulatory setting typically at least 20 hours per week, and
- An intensive outpatient program, or IOP, in which outpatient behavioral health services are provided for between 9 and 19 hours per week. Note that for adolescents and children, IOPs of just six hours a week are acceptable.
IOP billing tends to be a bit of a challenge compared to inpatient and hospital-based programs, due in part to the multiple treatment modalities and service types involved in this type of treatment.
Services typically covered in IOPs
Generally, IOPs must be licensed at the state level and individuals must receive at least two hours of services per day. Most programs meet three or five days per week for two to three hours a day. IOPs usually treat substance abuse and certain mental health disorders and the types of services generally covered include:
- Individual psychotherapy
- Group psychotherapy
- Family psychotherapy
- Multi-family psychotherapy
- Psycho-educational services
- Medical monitoring
According to CMS guidelines, in order to be eligible for reimbursement, all IOP services must:
- Be supervised by the attending provider.
- Be consistent with an individual treatment plan that addresses the problems requiring the admission and consistent with clinical best practices.
- Be reasonably expected to improve the patient's presenting problem within a reasonable amount of time, typically between 12 and 16 weeks.
A look at HCPCS and revenue codes for IOPs
IOP billing codes will depend on whether the services are provided primarily for substance abuse or for mental health issues. It's important to note that if a patient is receiving treatment with a dual diagnosis of substance abuse and mental health disorder, you can generally only bill for one IOP session per day even if both issues are addressed in treatment. You may document that information for the payer, but duplicate billing claims will typically be denied except in very narrow circumstances.
- S9480 is the per diem outpatient IOP code for psychiatric issues including eating disorders; it is paired with the 0905 revenue code. Note that this HCPCS code is for private payers only; Medicare does not recognize this code.
- H0015 is the per diem outpatient IOP code for chemical dependency; it is paired with the 0906 revenue code.
For most payers, these IOP services are considered an integral part of the per diem rate and cannot be billed separately in addition to the above HCPCS codes:
- Ancillary services
- Diagnostic testing and evaluations, including neuro-psychological testing
- Lab tests including drug and alcohol tests
- Medication management
- All therapy sessions, including individual, group, and family
- Crisis intervention
Other things to keep in mind about IOP billing
Most insurance companies require pre-authorization before they will reimburse for IOP services. In addition, even though an IOP can technically provide just two hours of services per day, most private payers require 180 minutes of active therapy per day in order to reimburse the per diem rates. For this reason, clinical documentation supporting the full 180 minutes of services is essential.
Related Article: 6 Key Steps of a Successful Medical Billing Process
Physician services generally cannot be billed separately unless the IOP is provided in a hospital setting. For ambulatory facilities, physician services are included in the per diem rate.
Most payers will require re-authorization after 90 days and few authorize IOP care past 180 days. These are considered short-term interventions.
If you have any questions about IOP billing or how to maximize your reimbursement for mental health and substance abuse treatment services, contact me today for a free consultation at 770-666-0470 or email me at firstname.lastname@example.org.