There are some important questions to address around this topic. We have asked this same question a thousand times directly to carriers. It seems there are variables per plan and it is NOT the same as billing weekly therapy visits on an ROP case vs. just the once a month visits with psychiatrist/med management on a PHP/IOP basis.
Can you bill the H0015 code on a 1500 form?
No, H0015 is a “per diem” fee and must be billed on UB04.
To determine whether you can bill the H0015 code on a 1500 form, it is necessary to consult the guidelines and policies of the specific payer or insurance company you are dealing with. Each payer may have its own set of rules regarding which services can be billed on the 1500 form and what documentation is required.
Typically, the CMS-1500 form is used for outpatient services, while the UB-04 form (also known as the CMS-1450 form) is used for inpatient services. However, specific rules may vary depending on the payer and the type of service being provided.
If not what CPT code would you use for the physician fees?
H0015 is a CPT code that describes alcohol and/or drug services. It is used to describe intensive outpatient treatment programs that operate at least 3 hours/day and at least 3 days/week and are based on an individualized treatment plan1. The code includes assessment, counseling, crisis intervention, and activity therapies or education.
To identify the correct CPT code, consider the following information:
- Procedure or service description: Determine the exact nature of the procedure or service provided by the physician. This may include diagnostic tests, surgeries, consultations, or other medical interventions.
- Documentation and guidelines: Review the documentation and guidelines provided by the American Medical Association (AMA) in the Current Procedural Terminology (CPT) manual. The manual contains a comprehensive list of CPT codes along with descriptions, guidelines, and associated services.
- Code selection: Based on the procedure or service description, identify the most appropriate CPT code that accurately represents the work performed by the physician. The code should align with the specific procedure, service, or evaluation provided.
Do you have to have both the UBO4 charges and the 1500 form or can you bill the physician charges without facility charges?
Facilities commonly have apprehensions as they look into this more is that they are unable to provide IOP due to being a private practice. What has normally been seen is the S9480 code is needed and has looked like it has to be billed on the UBO4.
This depends on if you can separate out a psych visit at the IOP level. It would depend on if the plan requires psych visits included with IOP per diem, which most do. Some plans allow for outside provider psych visits to be done along with a coordination of care. However, when possible, the psych visit can be billed out separately- it would be billed on a HCFA-1500 as professional. IOP services are billed on UB04 since those are “per diem” fees. In some cases, this would need to be on a different day than the IOP service.
Again, here are a few scenarios to consider:
Professional services only: If the physician provided professional services without any facility-related services, you may typically bill only the physician charges using the CMS-1500 form. The CMS-1500 form is commonly used for professional services provided in an outpatient setting.
Facility and professional services: If both facility-related services (such as hospital or clinic services) and physician services were provided, you may need to submit two separate claims. The facility charges would be billed on the UB-04 form, which is commonly used for institutional claims, and the physician charges would be billed on the CMS-1500 form.
Facility-based professional services: In some cases, certain professional services may be considered facility-based, where the physician’s services are directly associated with a specific facility. In such instances, the facility charges and the associated professional services may be billed together on the UB-04 form.
Please let us know any questions in the comment section. Axis helps with hourly consulting and partnering on licensing, accreditation, and billing as well.
Meanwhile, have a look at our coding and billing cheat sheet.