Billing for IOP in a nutshell
Are you seeing changes in IOP billing for mental health in 2023? We certainly are. There are new requirements coming from UHC, BCBS, Cigna, Aetna and all the rest for all levels of care including RTC and PHP billing all the way through outpatient services.
When dealing with IOP billing specifically, there are generally a few more requirements and consistent attention needed to make sure everyone involved is happy. From the patient being able to continue their treatment, to the doctors treating the patient, and of course, making sure the insurance companies are on board with allowing the overall treatment to happen.
Behavioral health levels of care
Behavioral health facilities essentially provide four types of services that insurance companies may consider reimbursement when treating a patient.
- Hospital-based inpatient programs, that require medical monitoring, nursing care, and other behavioral health services treated 24/7.
- Residential treatment programs, also known as RTC, which is more of a sub-acute facility based monitoring, offering other behavioral health services.
- Partial hospital programs, better known as PHP, providing services in an ambulatory setting, and generally requires 20 hours per week.
- Intensive outpatient programs, known as IOP, where the patient is provided with behavioral health services for at least 9 to 19 hours a week for adults, and for children and adolescents at least six hours is generally acceptable.
There are so many different modalities and service types when billing for IOP, compared to inpatient and hospital-based programs, which in turn makes it more challenging when trying to get reimbursement.
Similar Article: The Secret To Getting Reimbursed Quicker- Claims Follow Up
Typical services covered in IOPs
If a facility is offering IOP services, they must be licensed at the state level and usually will treat substance abuse and most mental health disorders. Most facilities will set up a weekly schedule for IOP patients, consisting of meeting at least two hours per day, and from three to five days a week.
Typical services generally covered are:
- Individual psychotherapy
- Family psychotherapy
- Group psychotherapy
- Psycho-educational services
- Medical monitoring
CMS guidelines required in order for the facility to be eligible for reimbursement for IOP services are:
- The attending provider must supervise the patient at all times.
- Adhering and being consistent with the initial treatment plan for the patient.
- Addressing the diagnosis(s) that required admission.
- Being consistent with clinical best practices. (Clinical are an important determining factor in authorization and concurrent authorization for the patient.)
- Having a responsible expected time to treat the patient, generally allowing between 12 to 16 weeks of IOP care.
HCPCS and revenue codes for IOPs
IOP billing codes may differ depending on what the patient’s diagnosis is, and what services are provided primarily either for substance abuse or for mental health issues. Also, another thing to remember when billing for IOP services, if the patient has a dual-diagnosis for both substance abuse and mental health, you can generally only bill for one IOP session per day, even if both were being addressed in therapy. It is always good to document that information for the insurance company, but beware to not submit duplicate claims, as they’ll inevitably get denied and or delay payment.
- S9480/0905: The per diem outpatient IOP code for psychiatric issues which may include eating disorders, is S9480, and most times is always paired with revenue code 0905. This is generally used for private payers, as Medicare does not recognize these codes.
- H0015/0906: The per diem outpatient IOP code for all chemical dependency is H0015, and is always paired with revenue code 0906.
Similar Article: 5 Insurance Billing Errors Drug Treatment Centers Can Avoid
Pre-authorization, clinical and IOP all go hand in hand
Just like with all inpatient level care services, most insurance companies require all IOP services obtain a pre-authorization before reimbursement is complete. Although IOP, technically provides only two to three hours per day, most payers require at least 180 minutes of active therapy per day in order to reimburse the per diem rates.
This is why I stated earlier, that clinical documentation is a key element in supporting the full 180 minutes per day, otherwise you’ll end up with a denied claim. A concurrent authorization is generally required to continue to treat the patient and sometimes referred to as short-term interventions, where all clinical and progress of the patient is considered and decided for continued authorization.
We hope this was a helpful and informative article about IOP in particular. If you have any questions about IOP billing and how to maximize your reimbursement for behavioral health services or any other billing concern, please feel free to contact us via email, or check out a ton of extra billing resources here.
Do you know if LPCC’s can bill for IOP
Hello,
Great question. This would depend on the insurance carrier and the state you are in. If you have further details we could help get a more accurate answer. Feel free to call anytime!
yes any licensed bhp can
Can insurance be billed if I only have one client in an IOP group? If a session is 3 hours and I can’t bill as IOP can I bill as a 3-hour Individual session?
This is an interesting question and would depend on the plan and their guidelines. Normally, if services were rendered and the patient is meeting the weekly hours for IOP, you can submit the claim for that level of service. Either way, you could submit the claim for a group under that plans code for that service.
Happy to discuss further if you want to give us a call as well.
Can H0004, H0005 and H0006 be bill on the same date of service?
This is highly unlikely as insurance will normally only cover one behavioral health service per day. Their could be specific modifiers that would allow something like this, and it would depend on the policy of each plan.
One more question, can you bill H004 and H0015 together? Thank you for sharing your knowledge.
This is unlikely to be reimbursed. With H0015 being a per diem reimbursement, carriers will not usually let you bill for therapeutic services as well on the same day.
I meant to say H0004 in conjunction with H0015. I missed an extra Zero.
If a client is in a behavioral health residential facility, can they also be attending an IOP 5 days a week?
If a client is in a behavioral health residential facility, can they also be attending an IOP 5 days a week?
This is an interesting question. Not sure how this is logistically possible, but for insurance purposes, this is not an option. Residential treatment is considered 24 hour clinical care.
Are modifiers used when billing for prescribers(APN, MD) contracted to provide services in an IOP ( dual diagnosis)?
For instance CPT code E&M 99213, with modifiers 95 (TelePsych), HF(substance use program), & if non-physician, SA ( nurse practitioner, physician assistant).
These prescribers use the above modifiers when in their private clinics.
This is a great couple of questions that do have some variables.
Yes, modifiers are often used if there are multiple services for Mental Health on the same date. Depending on the plan criteria, these extra services could be a part of the criteria for the daily rate for IOP…. so it depends.
If a patient is approved IOP, it is unlikely insurance will allow for outside services to be reimbursed. We would be happy to discuss this on a call if needed. Please email info@axisirg.com for further information or to set up a time to chat!
What is the bill type for H0015 on a Ub04?
Marta,
H0015 is IOP substance abuse as a primary diagnosis and is normally paired with revenue code 0906.
What are you trying to bill for specifically?
Can H0015 and 90837 be billed on the same day ? Should they be billed on the same day ?
Great question,
No, 90837 is normally included in the daily rate for H0015. This is not something that is done one way or the other.
Hi there, we are an outpatient mental health psychotherapy office, and have numerous patients that can be in IOP or PHP at any given time. If they were to leave their program, or have those IOP/PHP services during the day and then come for a session with us in the afternoon, would we be able to bill our 90837 since they are technically in IOP/PHP? We do not provide IOP/PHP, but they are normal/regular clients of ours who have gone into these programs but still want to continue sessions with their normal therapist.
Jackie,
It would be rare – even with modifiers, for insurance to cover a per diem PHP/IOP day and reimburse for a 90837 session from the same NPI/Tax ID program. It may be possible if the 90837 was done by an outside provider, but unlikely if it is on the same day – or even same authorization period as the PHP/IOP. Really the only way to know is to contact your credentialing contract rep and see if this is possible, or submit the claim and see what kind of denial you get.
Hi i’m having patients with differents program IOP , PHP , OP, an im strugling with a patient have 3 session per day (3hrs group session IOP , 3 hrs group session PHP , 1hrs indivi session IOP ) , for Substance abuse day treatement , so i know that i need to bill those claims under professional claims but what i dont know is which since he has 3 sessions per day with different programs so my question was what procedure codes and what modifier i can use we know that the place of service was in the office it’s 11
These would actually be institutional claims. Carriers do not allow you to bill PHP and IOP on the same day, so whatever set up you have for that is a no go. If you are billing services done in the office for the place of service, then you need to bill professional services using the codes for whichever service and a modifier is needed- to show that the services are separate and distinct- modifier 59 is what is normally used for that.
What is the maximum hours billable for an IOP program per day, per client?
IOP services range from 9-15 hours per week. It is a per diem reimbursement, so you are not billing per hour, just more for the daily fee for your IOP program.
My apologies I asked the wrong question. My original question was supposed to be can H0015 and H0004 be billed on the same date of service? and can H0015 and T1016 be billed on the same date of service
Hello,
No problem! H0015 is a per diem all inclusive rate. We have not seen previous claims for all carriers allow for any secondary code/service to be billed on the same day.
Hi! Your help here is very much appreciated!
(1) Can a physician do a group in PHP or IOP and bill separately for the service or does the physician need to be paid our of the facility’s PHP/IOP billing and is the answer different for private insurance vs. Medicare?
(2) If a physician can bill separately for conducting group therapy sessions, can they bill for multiple group therapies in a day if they are on different topics?
Thanks in advance!
If billing IOP or PHP – the group would be included in that codes “all inclusive” fee.
I know Medicare won’t pay for S9480 but I need Medicare to deny the S9480 so I can bill to Medicaid. Medicare keeps denying the S9480 on the front end requiring a modifier. What modifier to I need to get Medicare to deny so I can bill Medicaid?
We would need to know what the modifier is for- this is unusual and would have some variables to get a correct answer.
You can add GY Modifier with CPT S9480 .
Correct, Adding the GY HCPCS modifier to the CPT code indicates that an “item or service is statutorily excluded or the service does not meet the definition of Medicare Benefit.” This will automatically create a denial and the beneficiary may be liable for all charges whether personally or through other insurance.
Where does the 0905 revenue code goes on the 1500 form when billed with the S9480?
Also, can the 0905 be billed from an office setting or just facility? if just facility, what revenue code can be billed with the S9480 in an office setting.
Hello,
S9480 normally does not get billed on aHCFA 1500, its billed on a UB04.
You guys should have an Email List? This is so cool. Most of these billing companies in California treat you like dirt and hat to answer your questions.
Do you have a list of facilities in California that accept:
United Healthcare Medicare Advantage Choice Plan 1 PPO
Do you know how long it takes to get approved for United Healthcare Medicare Advantage ?
Hello!
We do have a email subscriber list when we post new content.
We do not have a list of facilities that accept United Healthcare Medicare Advantage Choice Plan 1 PPO.
However we do help with credentialing. It can take 2-6 months to get approved.
Give us a call, happy to help.
Hello – I am new to coding/billing and reimbursement for IOP ASAM level licensure 2.1 for a CMHC in CO. I was informed that our IOP providers are not “bundle billing.” I take this to mean they are unbundling the services. I also did some research for Medicare beneficiaries participating in IOP services and it looks like they do NOT reimburse for IOP. I was wondering how this program can be sustainable if Medicare is not reimbursing? My question to you is, how are IOP services being billed to Commercial insurance (BCBS, UHC, ANTHEM, AETNA…)? What codes are being used for billing & reimbursement and what claim form is used? In CO, RAE 1, is being used with H0015. Beyond this, I am unsure of the correct way moving forward with Medicare and Commercial. Please advise. Thank you.
There is a bit to unbundle here in this post.
IOP programs that are focused around Medicare reimbursement have quite a bit of variables to make a profitable. Programs need to be credentialed with Medicare to get reimbursement.
IOP services are billed on UB04 – billing for the facility fees as an all inclusive fee. The codes will differ depending on what specific treatment they are receiving.
1. When doing an assessment prior to the client starting in an IOP what CPT code so you use for the assessment? Is it still the 90791 code? We are starting a new IOP program and have a lot of questions.
2. Can we bill for the medical directors time and if so how do you do that?
Great questions!
1- 90791 is correct for the assessment prior to admitting to IOP.
2- this is normally not an option.
I would like to say “This is awesome!”. Most companies would not take the time to assist others and would charge for this type of information.
Question: Is there a modifier for code 0906 when the (IOP) service is provided via Telehealth and if so what POS code should be utilized? Any assistance or guidance would be greatly appreciated.
Hello,
We actually get asked this question a lot.
There isn’t a modifier for IOP services if you are billing facility fees, if billing professional fees, the modifier is GT or 95 with POS being 02.
I am sorry and please correct me if I am wrong. I guess POS 02 is used when the patient is taking the services via telehealth but not at his/her own house and if treated at own house then POS required is 10 ?
This really depends on the carrier and plan.
For dates of service on and after January 1, 2024:
Report place of service 10 for services when the patient is in their home.
Use modifier 95 through December 31, 2024, when:
The clinician is in the hospital and the patient is in their home.
Outpatient therapy provided via telehealth by PTs, OTs or SLPs.
Providers should continue to bill claims for telehealth services with the POS if the service had been done in person and modifier 95 through December 31, 2023.
The Centers for Medicare and Medicaid Services (CMS) requires providers to use modifier -95 to indicate that telehealth services are being provided. This modifier replaced -GT and -GQ, which CMS stopped using several years ago. However, private payors may have different modifier requirements. For example, some private insurance companies still accept the GT modifier. To ensure maximum reimbursement, it’s best to verify which modifiers your insurance company accepts most widely.
I have a question as I have gotten several different answers regarding IOP for Medicare clients. For group presenters does Medicare or CMS require that each group have a different presenter as I have been informed that if you have one presenter for the three groups in one day Medicare see it as one group.
Interesting question,
Medicare and other private insurance usually just need a certain amount of hours for clinical treatment to be met. IOP is a daily rate and not broken down by per groups, per day.
What is the location code for IOP in a office approved/licensed outpatient location? What is the form to bill claims for Tricare?
Do I need to use any modifier? Are only psychiatrics
Great question!
Is this mental health or substance abuse IOP? The per diem code is normally S9480, however TriCare can be fickle… soare there could be some variables.
Are you submitting through the member side or provider side? Sometimes Tricare will have their own specific claim forms. Normally it would be through a CMS1500 OR UBO4.
Sorry, didn’t see your answer earlier. It is for mental health. The office is a free standing IOP. I found out it is a UB 04 form and I am using Xpress Claims site, however keep getting the message “Bill class” and “frequency” are not consistent and the claim is rejected. What would be this code for Tricare? I need to find out ‘facility type” and ‘frequency” code. I am submitting through provider side. Thank you!
Yeah there are some subtleties and sometimes finesse (throwing a dart at a board).
TRICARE insurance billing for mental health services can be complex and there are several factors that need to be consistent in order to avoid claim rejections.
The first factor is the “Bill class,” which refers to the type of service being billed. Mental health services are typically billed as outpatient services, and the bill class code for outpatient mental health services is 0915.
The second factor is the “Facility type,” which refers to the type of facility where the service was provided. Mental health services can be provided in a variety of settings, including clinics, hospitals, and private offices. The facility type code for mental health services can vary depending on the specific setting, but it is important to make sure that the code is consistent with the setting where the service was provided.
The third factor is the “Frequency code,” which refers to how often the service was provided. For mental health services, the frequency code is typically either “1” for a single session or “2” for multiple sessions.
In order to avoid claim rejections, it is important to ensure that all of these factors are consistent on the claim form. For example, if the bill class is listed as 0915 for an outpatient mental health service, the facility type should also be consistent with an outpatient setting, and the frequency code should reflect the number of sessions provided. Any inconsistencies can result in a claim rejection, which can cause delays and require resubmission of the claim.
Type of Bill Code Structure
This four-digit alphanumeric code provides three specific pieces of information after a leading zero. CMS (Centers for Medicare & Medicaid Services) ignores the leading zero. This three-digit alphanumeric code gives three specific pieces of information.
• First Digit = Leading zero. Ignored by CMS (Centers for Medicare & Medicaid Services)
• Second Digit = Type of facility
• Third Digit = Type of care
• Fourth Digit = Sequence of this bill in this episode of care. Referred to as a “frequency” code
Type of Facility
• CMS (Centers for Medicare & Medicaid Services) processes this as first digit
Type of Facility
Second Digit Description
1 Hospital
2 Skilled Nursing Facility (SNF)
3 Home Health
4 Religious Nonmedical (Hospital)
5 Religious Nonmedical (Extended Care) discontinued 10/1/05
6 Intermediate Care
7 Clinic or Hospital based End Stage Renal Disease (ESRD) facility (requires Special second digit)
8 Special facility or hospital (Critical Access Hospital (CAH}} (Ambulatory Surgical Center (ASC}} surgery (requires special second digit)
9 Reserved for National Assignment
Type of Care
Third Digit Description
• Except Clinics & Special Facilities – Inpatient Part A
• Clinics Only – Rural Health Center (RHC)
• Special Facilities Only – Hospice (non-hospital based)
• Except Clinics & Special Facilities • Inpatient (Part 8) (includes Home Health Agency (HHA) visits under a Part B plan of treatment)
• Clinics Only • Hospital based or Independent Renal Dialysis Center
• Special Facilities Only• Hospice (hospital based)
• Except Clinics & Special Facilities – Outpatient visits under a Part A plan of treatment and use of under a Part A plan of treatment
• Special Facilities Only – Services to Hospital Outpatients
Except Clinics & Special Facilities – Other (Part B) (includes HHA (Home Health Agency) medical and other health services not under a plan of treatment, SNF (Skilled Nursing Facility) diagnostic clinical laboratory services for “nonpatients,” and referenced diagnostic services)
• Clinics Only – Other Rehabilitation Facility (ORF)
• Special Facilities Only – Free Standing Birthing Center
• Except Clinics & Special Facilities – Intermediate Care – Level I
• Clinics Only – Comprehensive Outpatient Rehabilitation Facility (CORF)
Special Facilities Only – CAH (Critical Access Hospital)
• Except Clinics & Special Facilities – Intermediate Care – Level II
⚫ Clinics Only – Community Mental Health Center (CMHC)
• Special Facilities Only – Residential Facility (not used for Medicare)
• Except Clinics & Special Facilities – Subacute Inpatient (Revenue Code 019X required) Eight Swing Beds (used to indicate billing for SNF (Skilled Nursing Facility) level of care in a hospital with an approved swing bed agreement.)
⚫ Clinics Only – Free-standing Provider-based Federally Qualified Health Center (FQHC)
• Special Facilities Only – Reserved for National Assignment
• Except Clinics & Special Facilities – NA (Non-assigned (Claim))
⚫ Clinics Only – Reserved for National Assignment
• Special Facilities Only – Reserved for National Assignment
• Except Clinics & Special Facilities – Reserved for National Assignment
⚫ Clinics Only – Other
• Special Facilities Only – Other
Frequency
• CMS (Centers for Medicare & Medicaid Services) processes this as third digit
Fourth Digit Description
Non-payment/Zero Claim – Use when it does not anticipate payment from payer for the bill, but is informing the payer about a period of non- payable confinement or termination of care. “Through” date of this bill (FL (Form Locator) 6) is discharge date for this confinement, or termination of plan of care
Admit Through Discharge – Use for a bill encompassing an entire inpatient confinement or course of outpatient treatment for which it expects payment from payer or which will update deductible for inpatient or Part B claims when Medicare is secondary to an Employer Group Health Plan (EGHP)
Interim – First Claim – Use for first of an expected series of bills for which utilization is chargeable or which will update inpatient deductible for same confinement of course of treatment. For HHA (Home Health Agency)s, used for submission of original or replacement RAP (Resident Assessment Protocol)s
Interim-Continuing Claims (Not valid for Prospective Payment System (PPS) Bills) – Use when a bill for which utilization is chargeable for same confinement or course of treatment had already been submitted and further bills are expected to be submitted later
Interim – Last Claim (Not valid for PPS (Prospective Payment System) Bills) – Use for a bill for which utilization is chargeable, and which is last of a series for this confinement or course of treatment
Late Charge Only – These bills contain only additional charges; however, if late charge is for:
⚫ Services on same day as outpatient surgery subject to ASC (Accredited Standards Committee or Ambulatory Surgical/Surgery Center) limit;
Services on same day as services subject to Outpatient PPS (Prospective Payment System) (OPPS);
• ESRD (End Stage Renal Disease) services paid under composite rate;
• Inpatient accommodation charges;
⚫ Services paid under HH (Home Health) PPS (Prospective Payment System); and
• Inpatient hospital or SNF (Skilled Nursing Facility) PPS (Prospective Payment System) ancillaries.
It must be submitted as an adjustment request (xx7).
Fourth Digit Description
Replacement of Prior Claim (See adjustment third digit) – Use to correct a previously submitted bill. Provider applies this code to corrected or “new” bill
Vold/Cancel of Prior Clalm (See adjustment third digit) – Use to indicate this bill is an exact duplicate of an incorrect bill previously submitted. A code “7” (Replacement of Prior Claim) is being submitted showing corrected information
Final claim for a Home Health PPS (Prospective Payment System) Period
Admission/Election Notice for Hospice – Use when hospice or Religious Non-medical Health Care Institution is submitting Form CMS (Centers for Medicare & Medicaid Services)-1450 as an Admission Notice
Hospice Termination/ Revocation Notice – Use when Form CMS (Centers for Medicare & Medicaid Services)-1450 is used as a notice of termination/revocation for a previously posted Hospice/Medicare Coordinated Care Demonstration/Religious Non-medical Health Care Institution election
Hospice Change of Provider Notice – Use when CMS (Centers for Medicare & Medicaid Services) Form-1450 is being used as a Notice of Change to Hospice provider
Hospice Election Void/Cancel – Use when Form CMS (Centers for Medicare & Medicaid Services)-1450 is used as a Notice of a Void/Cancel of Hospice/Medicare Coordinated Care Demonstration/Religious Non-medical Health Care Institution election
Hospice Change of Ownership – Use when Form CMS (Centers for Medicare & Medicaid Services)-1450 is used as a Notice of Change in Ownership for hospice
Beneficiary Initiated Adjustment Claim – Use to identify adjustments initiated by beneficiary. For FI (Fiscal Intermediary) use only
CWF (Common Working File) Initiated Adjustment Claim – Use to identify adjustments initiated by CWF (Common Working File). For FI (Fiscal Intermediary) use only
CMS (Centers for Medicare & Medicaid Services) Initiated Adjustment Claim – Use to identify adjustments initiated by CMS (Centers for Medicare & Medicaid Services). For FI (Fiscal Intermediary) use only
FI (Fiscal Intermediary) Adjustment Claim (Other than QIO (Quality Improvement Organization) or Provider) – Use to identify adjustments initiated by FI (Fiscal Intermediary). For FI (Fiscal Intermediary) use only
Initiated Adjustment Claim/Other – Use to identify adjustments initiated by other entities. For FI (Fiscal Intermediary) use only
OIG (Office of the Inspector General) Initiated Adjustment Claim – Use to identify adjustments initiated by OIG (Office of the Inspector General). For FI (Fiscal Intermediary) use only
MSP (Medicare Secondary Payer) Initiated Adjustment Claim – Use to identify adjustments initiated by MSP (Medicare Secondary Payer). For FI (Fiscal Intermediary) use only. Note: MSP (Medicare Secondary Payer) takes precedence for other adjustment sources
Nonpayment/Zero Claims – Used to report nonpayment claims. It is required to extend the spell of illness or benefit period or to inform the payer of a non-reimbursable period of confinement or termination of care.
QIO (Quality Improvement Organization) Adjustment Claim – Use to identify adjustments initiated by OIO (Quality Improvement Organization). For FI (Fiscal Intermediary) use only
Reopening/Adjustment – Use when the submission falls outside of period to submit an adjustment bill
Is there a code for Non-intensive outpatient groups? N-IOP? This group would meet 2xweek for 2 hours each day for mental health diagnoses.
One common insurance billing code for non-intensive outpatient groups for mental health diagnoses is CPT code 90853. This code is used to bill for group psychotherapy services, which involve treating two or more patients in a group setting.
To use this code, the mental health provider must conduct a group therapy session that is typically around 60 minutes in length. During the session, the provider works with the group members to address mental health concerns, such as depression, anxiety, or substance use disorders.
It’s important to note that the use of this code is typically limited to certain mental health diagnoses, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Additionally, insurance companies may have specific requirements or limitations on the use of this code, so it’s always best to check with the patient’s insurance provider before submitting a claim.
You could possibly use modifier 59 to do 2 groups on the same day, however most carriers don’t allow for the same code on the same day.
Is it acceptable to provide S9840 via telehealth? If so, how is this indicated on the claim form?
Also, in what instances would you bill H0001 vs. 90791?
Thank you in advance! This information is so helpful.
S9480 is the actual code — a Healthcare Common Procedure Coding System (HCPCS) code used for telehealth services. However, whether or not insurance allows reimbursement for S9480 via telehealth will depend on the specific insurance plan and policy.
To indicate that the service was provided via telehealth on the claim form, you would need to use the appropriate modifier. The modifier for telehealth services is GT, which should be appended to the procedure code (S9480) when billing for telehealth services.
It is important to note that not all insurance plans cover tele-health and even those that do may have specific requirements or limitations. Therefore, it is recommended that you check with the insurance provider or consult the policy documentation to verify coverage and any necessary documentation or requirements for reimbursement.
H0001 and 90791 are two different procedure codes used in mental health services.
H0001 is a HCPCS code used for substance abuse assessment and counseling services. This code is used to bill for substance abuse counseling and treatment services, such as assessments, individual and group counseling sessions, and case management services. H0001 is typically used in the context of substance abuse treatment programs, where the focus is on treating addiction and related issues.
On the other hand, 90791 is a Current Procedural Terminology (CPT) code used for psychiatric diagnostic evaluation. This code is used to bill for initial psychiatric evaluations, where a clinician assesses a patient’s mental health condition, medical history, and related factors to arrive at a diagnosis and treatment plan. 90791 is typically used in the context of mental health treatment, where the focus is on addressing a wide range of mental health conditions.
Therefore, you would bill H0001 when providing substance abuse assessment and counseling services, and 90791 when providing psychiatric diagnostic evaluation services for mental health conditions. It’s important to note that the appropriate code to use may depend on the specific services provided and the requirements of the payer. Therefore, it’s always a good idea to consult with the payer or a coding specialist to ensure that you are billing the appropriate code for the services provided.
Hello! I am having a hard time finding which CPT codes Medicare will accept for IOP. I know that some use 90853 but the reimbursement rate for that is around $20 and our provider is spending around 3 hours per group session with the patients so this seems to not be the correct code. I have looked at the Medicare mental health manual but it does not specifically talk about IOP services. Any guidance you can give me would be much appreciated. Thanks!
This is a great question!
Normally 90853 is not separated out from IOP per diem claims. Some of the below codes are what Medicare has suggested previously for IOP.
$20 per claim is the Medicare average on occasion because there are normally multiple patients being able to receive benefits in the group for that same service. So theoretically, as medicare and other carriers see this, the provider is being reimbursed for 8-20 patients for the same group 90853 service.
The Centers for Medicare & Medicaid Services (CMS) publish the Medicare Physician Fee Schedule (MPFS) every year, which includes the current procedural terminology (CPT) codes and reimbursement rates for various medical services, including intensive outpatient programs (IOP) for substance abuse.
However, the reimbursement rates may vary based on factors such as geographic location, individual patient characteristics, and other circumstances. It is recommended that you contact Medicare or consult with a healthcare billing professional for more specific information.
That being said, here are some CPT codes commonly used for IOP for substance abuse treatment that Medicare may accept:
H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
H0016: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 6 hours/day and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
H0017: Alcohol and/or drug services; intensive outpatient (treatment program that operates less than 3 hours/day and less than 5 days/week), including assessment, counseling; crisis intervention, and activity therapies or education
Please let us know any questions!
First off, this thread of questions and answers has been so helpful! I really appreciate your willingness to teach and share the wealth of knowledge you all have!
I have a few questions I could use some clarity on:
We are looking to expand our behavioral health practice into including and IOP. I realize the correct code to use would be S9480 but we’ve never used it before and I want to make sure I understand how it works.
1. How many patients are allowed to be in an IOP together? The rate for S9480 is the same as 90837 and yet it’s per diem and could be about 3 hours a day. It just doesn’t seem sustainable/profitable unless we have a certain amount of patients per program.
2. Can S9480 ever be billed on a CMS 1500 without the revenue code or must it always be on UB-04?
3. A little clarity on how to bill using the S9480 code would be very helpful…for example is we had 3 patients in the program and they met for 3 hours a day 3 days a week. What would that look like in terms of insurance billing?
Greatly appreciate your help!
The specific number of patients allowed in an Intensive Outpatient Program (IOP) for behavioral health can vary depending on the state, program, facility, and the resources available. However, there is no universally fixed limit on the number of patients that can participate in an IOP.
The capacity of an IOP can depend on factors such as the size of the facility, the staffing levels, the treatment philosophy, and the specific needs of the patients. Some IOPs may have smaller groups with fewer patients to allow for more individualized attention and a more intimate therapeutic environment. In contrast, others may accommodate larger groups if they have the resources to support it.
S9480 will generally be billed on UB04 since it is a per diem fee although some insurance carriers that carve out with UHC will require HCFA/CMS 1500. Unlikely, but there could be a published list of those requiring S9480 be billed HCFA/CMS 1500.
Carriers change billing requirements often, up-to-date information on specific insurance carriers and their billing requirements can be frustrating. Each insurance carrier may have their own policies and guidelines regarding billing procedures, including which forms should be used for specific services.
To obtain accurate and current information on insurance carriers that require S9480 (which appears to be a Healthcare Common Procedure Coding System code for Intensive Outpatient Psychiatric Services) to be billed on the HCFA and CMS 1500 forms, we can help, and recommend reaching out to the specific insurance companies or consulting the provider manuals and billing guidelines provided by those carriers.
Insurance carriers often are not allowed to inform providers how to bill or which codes to use, unfortunately.
Peter, thank you for your helpful and thorough response!
You are very welcome, please let us know anything further you find out!
Hi Amanda,
My practice is starting this same process. Any updates on how it’s going for you? We’re having the same issues with figuring out how to bill. Seems I get a different answer depending who I talk to. Any advice is appreciated!
Do you know who can refer a patient to an IOP program? Can it be any type of professional such as a LPN, MD, PA, NP, social worker, etc?
Any clinical professional can refer a patient to an IOP program. However, each insurance carrier may have their own requirements on what type of referral is needed, and authorization of benefits will most likely depend on medical necessity criteria.
Hello! I work for a mental health provider, and we are looking for some clarity regarding attendance and billing for IOP/PHP programming. Our IOP program is 3 hours a day,5 days a week and during that time a patient could be pulled out of programming for an individual E/M session with a psychiatrist. This would be billed separately by the performing provider. In reviewing a reimbursement policy by one of our payers, they have the definition of IOP/day treatment as follows:
“Day Treatment is a specific programmatic service where the patient attends a minimum of three
hours per day and generally 3-5 days per week. The services provided within these hours may
include group therapy, living/social skills building groups, educational groups, and some
individual therapy.”
After subtracting the time spent with the provider, this would be less than the minimum of three hours. Would this mean we would be unable to bill the daily facility rate if we are billing separately for the physician? Does the patient have to attend 3 hours in order to bill, or is it just that the program has to consist of 3 hours in order to be called an IOP program? Any advice is much appreciated!
This question has some variables.
Generally IOP is at least 3 hours per day of clinical services. If you are not meeting the minimum requirement for each carrier, you would not be able to submit claims on a per diem basis. It may be more beneficial for the patient if the psychiatrist time is included in the clinical hours needed for IOP. Those psych visits normally do not have a super high reimbursement amount either way.
The patient has to attend at least 3 hours in this case to bill, it would not matter how long the program is.
Please HELP. I am struggling with ChampVA due to Condition Codes, occurrence codes and value codes denying our behavioral health PHP (partial hospitalization) claims. We have used bill type 13X and we have attempted to bill for Condition code 41 (to indicate PHP). When used solely this too denied. We then billed for condition code 41 AND occurrence code 40 (scheduled date of admission). This too denied. Are they looking for multiple occurrence codes? Or is there something CHAMPVa is looking for in particular? AND are they needing the value codes be used? I can find absolutely no resources to reference ChampVa and these specific codes, and of course their CSR’s can only say so much. Please please help.
Yeah, ChampVA can be challenging with reimbursement as they act more like a fund than traditional insurance.
We have had success just billing them normally, although not every plan is the same.
We did not use condition or value codes, here is what we found.
H0031: Mental health assessment, by a non-physician
H0035: Partial hospitalization (PHP) services, per diem
H0036: Community-based psychiatric rehabilitation and support, per 15 minutes
H2011: Crisis intervention, per hour
H2035: Alcohol and/or drug services, group counseling
H0004: Behavioral health counseling and therapy, per 15 minutes
S9484: Behavioral health, counseling and/or therapy provided via synchronous telecommunication
T1015: Mental health case management
Are you using the 133 or 733 bill type frequency?
There are so many different bill type combinations that it is difficult to know which would be right for you to use.
First Digit = Leading zero. Ignored by CMS
Second Digit = Type of facility
Third Digit = Type of care
Fourth Digit = Sequence of this bill in this episode of care. Referred to as a “frequency” code
0133 would be Hospital, Outpatient, Interim – Continuing Claims
0733 would be Clinic or Hospital ESRD Facility, Outpatient, Interim – Continuing Claims
What is the UB-04 bill type for an IOP Residential facility?
Asad,
The IOP level of care does not normally include any residential benefits. There are different codes with different modifiers dpeending on the plan. We would need a bit more information on this question. What state are you in, what carriers you are contracted with, what is the clinical programming?
Dawn, I’m wondering if you were ever able to resolve your PHP claims w Champ VA? I’m having the same issue w them.
Help needed, we are a private practice with PMHNP and LPC providers, we are wanting to start an IOP program in office with PMHNP’s billing for IOP program. We bill for each provider individually on a HCFA 1500 form and each provider is credentialled individually. Will the clinic need to be credentialled on its own? Can we bill on HCFA 1500 and which codes would we use ?
It sounds like you have what is needed clinically. Congratulations on the IOP expansion.
Most carriers do require the group practice to be credentialed in-network as well for those benefits, although it is often is easier to get the group in-network if the providers already are. You can also navigate out of network as a clinic/group while getting credentialed. We do help with licensing, accreditation, and credentialing if you have further questions.
The form you would bill on for IOP institutional services would be a UB04 with code S9480 for mental health. Professional services can be done on a CMS 1500 form.
Hi Sofia,
My practice is starting this same process. Any updates on how it’s going for you? Any advice is appreciated!
Hi, the definition of H0015 includes at least 3 days/week, is the H0015 billed for each day of the week (since it is a per diem code) that the person is attending?
Correct, you would just want to make sure the patient is meeting the necessary clinical hours based on the criteria required by their insurance.
Hi, we are OON provider and want to know if we can bill Medication management, Individual session and family session on addition to the IOP S9480 for the same day? our patients are attending 2 hours of group and then remains 1 hour sometimes they attend individual with med management or 1 full hour of family and want to know if we can bill all those services for same day?
Great question!
In almost all cases you would not be able to unbundle services and bill them on the same day. Your options would be to either bill for the per diem IOP service or 1 group or 1 individual or 1 med management, but not all 3.
IOP most often consists of several treatment components, including individual counseling, group therapies, psychiatric care, medication management, education about a person’s condition and its management and complementary therapies, such as yoga or art therapy. Services billed as IOP (S9480 / H0015) can not be billed on the same day as outpatient therapy sessions.
Was there a specific plan / carrier you were inquiring about?
HI we are not participating with any insurance, and do not have any agreement on providing services as bundle and I see that for IOP adolescent is only requiring 2 hours of IOP, do you think then we can bill as above mentioned services additionally with IOP
That is good information and there can still be some variables.
Even for Adolescent IOP, the normal clinical hours required per day is 3. So just be sure on the requirements. Either way, it is unlikely insurance will let services of any sort be broken out and be reimbursed on along with the IOP per diem claim.
I have the same question BUT we do provide a 3hr IOP group session, then the patient stays after for a needed 1:1 session. I can see not billing this on the same day as IOP because we get the Per diem, but what if patient comes in on a day IOP is not held, can we now separately bill for the 1:1 session?
Stacy,
We have seen carriers pay for separate sessions if they are on a separate day from an IOP per diem day. However, the dates of service have to match when the actual 1:1 session takes place. If it is on the same day, even with a modifier, its very unlikely to be reimbursed.
Hello, would a urine drug test be included in the H0015 code? It is reimbursed on top of the per diem code?
This would depend on the plan. Most policies do not allow for UA screenings to be unbundled for primary SUD diagnosis patients.
Excellent thread! The issue I’m encountering is when patients are admitted to a PHP level of care but do not complete a full 20 hours of PHP in a given week. Our program calls for 5 days per week at 4-hour sessions, but on occasion, a patient will miss a day. In that case, can we bill IOP instead of PHP for that week of service (S9480 instead of H0035)?
Also, am I understanding that a visit with a psychiatrist for E/M & Psychotherapy (99214/90833) cannot be billed on the same day as PHP (H0035)? Similarly, Psychotherapy (90837) shouldn’t be billed on the same DOS as IOP (S9480)? These are all in the context of a commercial insurer.
I probably also should have clarified that the E/M service is directly related to the conditions for which the patient was admitted to PHP. Primarily, the psychiatrist is focused on medication management and occasionally also bills psychotherapy with the E/M service, documented as a distinct/separate service from the E/M.
Great question.
Normally authorization is approved and linked to a specific level of care RTC/PHP/IOP. You would not be able to bill a different or lower code that was linked to the authorization number. If a patient misses a day or does not complete the necessary hours for that level of care, you would not be able to bill for that day, although a lot of programs will have ancillary services after hours or on Saturday to make up for missed time.
You are also correct in that insurance will not normally allow for any E/M & Psychotherapy to be reimbursed on the same per diem approved treatment for PHP/IOP.
I have a question about IOP billing under S9480 for a Behavioral Health Center. IOP regulations for my state are 9 hours of group and 1 hour of individual therapy per week. Once a client meets certain requirements they will reduce their attendance (Wed group will be eliminated), we refer to this as step down. My question is, once they step down can the remainder of their weekly meetings (7 hours) continue to be billed as S9480, or do I need to use a different code (90853, H0046)?
We have been getting this question a lot and there is not a simple answer.
Normally insurance will tell you that the facility determines whether or not the patient met programming for a particular day or week.
If a patient misses hours or programming, it could be suggested they make up those hours with clinical assignments or applying skills learned in treatment in the real world and documented.
If a facility gets audited, they need to show that the patient met clinical hours for any day or week as the facility requires to meet programming.
Essentially, insurance is putting the requirements on the facility to make sure any authorized days that were billed for, meet the required criteria for the service. Its not black and white, but I would recommend you look at your contract with any carrier or talk to your credentialing rep on specifics. It is all quite variable – we can help with this as well.
We do offer consulting and training services in these areas, although again, it is quite carrier and plan specific to answer these questions in detail.
The other option is to bill for any stand alone Ind/Fam/Grp session that the patient attended but did not meet programming requirements for a per diem PHP/IOP.
Hi, I can not say how helpful this thread has been! My question is, do the providers for psyo-Ed groups and 1:1 individual sessions have to be independently licensed to bill for these services or credentialed under an independently licensed professional to do so for insurance re-imbursement?
Kelly,
Good question. Normally the specific requirements will be dictated by the state for licensing and also each insurance carrier. Some have more strict requirements than others as far as who can provide direct care. The majority of the time, the 1:1 sessions for group or individual therapy will have to be done by a licensed masters level therapist to get any reimbursement.
Hi thank you for all of the great information. when billing IOP for mental health who do we put down as the rendering provider on the UB04? Do we use the lead clinician or the provider who actually ran the groups that day? We run three separate groups per day during IOP hours so we might have three different clinicians.
Krissy,
We typically have not done claims billing for IOP groups submitted under each provider that ran the groups. We have seen most success in reimbursement when it had been billed under the lead clinician. More importantly, for IOP in insurance terms – is a per diem rate of reimbursement, normally it can only be billed once per day. Groups/Individual/Family therapy cannot be broken out for the authorized daily services.
This thread has been helpful! I do have a question, we are looking to add IOP to our private practice however I am very confused about the billing portion. We practice in NE. I have a few questions.
1. Can you bill the H0015 on a 1500?
2. If not what CPT code would you use for the physician fees?
3. Do you have to have both the UB charges and the 1500 or can you bill the physician charges without facility charges?
Our fear as we look into this more is that we are unable to provide IOP due to being a private practice. I have seen the S9480 but am seeing that it looks like it has to be on the UB.
Also if anyone has experience with credentialing in Nebraska can you help with the Medicaid ID I would need to set up for the practice?
Jackie,
These are all important questions.
1. Can you bill the H0015 on a 1500?
** No, H0015 is a “per diem” fee and must be billed on UB04.
2. 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.
3. Do you have to have both the UB charges and the 1500 or can you bill the physician charges without facility charges?
Our fear as we look into this more is that we are unable to provide IOP due to being a private practice. I have seen the S9480 but am seeing that it looks like it has to be on the UB.
**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.
Also if anyone has experience with credentialing in Nebraska can you help with the Medicaid ID I would need to set up for the practice?
**We provide licensing, accreditation, credentialing, and billing services in all states.
Ok – we are in Nebraska – billing IOP – we are billing H2014 for one provider, 90853 for another provider and 90834 (or comparable related code) for another provider. Payor is UHC Comm Health Plan & claims are denying for the same day service policy? I am new to IOP billing – what are we doing wrong lol Thanks!
Confused,
Very good question.
“CPT code H2014 is a HCPCS code for skills training and development. It is used for alcohol and drug abuse treatment services or rehabilitative services. It is billed per 15 minutes, and requires a modifier HQ for group services. It is used exclusively for Minnesota Health Care Program subscribers under the age of 21.”
So this may not work for Nebraska local plans.
This is one of the ancillary codes to use if IOP/PHP is denied for medical necessity adolescent use. It may or may not be used depending on the modifier and plan, but could be an option if it is in your network contract specifically.
For the 90853 and 90834 issue, it is not often that any plan will cover multiple mental health services on the same day, regardless of separate treating professionals and the correct modifiers used. The plan policy will trump the contract. If it is clear in your contract, you may have to get in contact with your someone at the carrier that can help push the claims through.
Hello, I am also new to IOP billing and this thread is pretty much helpful. Question though,
1. Can IOP be billed in a group practice?
2. Is it accurate to bill using S9408 per diem for group practice IOP?
Riza,
IOP can be billed in a group practice as long as you are meeting the criteria of each carrier. Assuming you are meaning S9480 and not S9408, you would be accurate in billing that code for most plans for IOP mental health.
If you are providing an intensive outpatient program (IOP) in a group practice setting and the services meet the requirements for S9480, you may use this code for billing per diem services. However, it’s essential to ensure that you meet all the specific criteria and documentation requirements set forth by the payer or insurance company you are billing. When billing with S9480, be sure to include the necessary documentation to support the medical necessity of the services provided, including the duration and intensity of the IOP treatment. Accurate and thorough documentation is crucial for proper reimbursement and to demonstrate that the services meet the criteria for this specific code.
Medical billing and coding can be complex, and using the correct codes is crucial for accurate reimbursement. It is advisable to consult with a certified medical coder or billing specialist [AXIS :)] who can review your specific situation.
Hi,
These threads are very helpful as I’m very new to IOP/PHP. For IOP CPT codes can these codes be billed on a CMS-1500 or are they only allowed on a UB-04? If they are only allowed on a UB-04 do you have any guidance that I can reference?
Amanda,
There are some variables to your question.
BILLING GUIDELINES
Procedure Codes
The two most commonly used codes for non-Medicare payers are:
H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
S9480 Intensive outpatient psychiatric services, per diem
Note: Both codes may not be billed together. Use one or the other depending on payer preferences.
Many carriers require the use of the UB-04 Claim Form and specify preferred “Type of Bill” (TOB) and “Revenue Codes” (RC) which are based on the type of facility and services being provided. For example, one payer states to use TOB 131, RC 0906 and HCPCS code H0015 for substance abuse IOP. However, for other psychiatric services IOP, they want providers to use TOB 131, RC 0905 with HCPCS code S9480.
If an independent practitioner with the appropriate licensure provides IOP, the services are submitted on the CMS-1500 using H2035 which is then reimbursed based on an hourly rate rather than the facility rate.
Before billing with H2035, check with the payer to determine if they have an ‘independent practitioner’ clause which would allow the additional reporting of services. The provider cannot be part of the billing facility staff in order to be considered ‘independent’ and must bill with the appropriate NPI. Be sure to use the proper number of units.
Is it possible for a provider to bill a physical exam prior to admitting a patient into the IOP program? They are trained in primary care as well and would like to do a physical exam and flu shots, hep c, etc. prior to admitting patients into the IOP program. Have you heard of this or is this possible?
This is interesting.
Because the services are done by the same clinician, you could run into some issues. It could be possible due to one service being medical and one being behavioral health. If the services are on different dates, you should be able to get reimbursement.
Aloha,
We have been billing H0015 with place of service 02 for telehealth IOP ever since Covid to one of Hawaii’s Medicaid insurers. They have paid our claims since then, but our last batch of billing dated July were all denied with reason being “Service not allowed in Place of Service.”
Was there an updated regulation or policy causing our denials?
Charmaine,
These can be frustrating situations as medicaid and other payers are constantly adjusting what codes and modifiers can be used togehter for proper billing in order to get reimbursement. They could have your license/npi updated inappropriately or some other administrative error on either side. It could be a contract expired or change in treating physician as well.
This is a case where you would need to call and get some help on their side to adjust the claims and push them through. We can help with this type of situation as well, unfortunately it does seem like there would need to be some extra work into finding out exactly what the issue is.
Can 90853 be billed on a UB if group session are being held at the facility?
Kerri,
the group code 90853 visits can be billed out separately- it would be billed on a HCFA-1500 as professional. IOP per diem services S9480 are billed on UB04 since those are inclusive.
Hello,
I am starting an iop in Philadelphia, pa. I wanted to know how to go about getting clients and what clinicians I can and should hire first to generate revenue. I also am taking the peer support counselor course can I bill for peer support counseling? How does that work?
All good questions here.
Please have a look here: https://axisirg.com/increasing-your-census-for-php-iop-behavioral-health/
and reach out to us for a consult on growing your business.
Is anyone having problems with getting authorizations approved by ambetter and magnolia? I can’t see to get mines approved.
Deidra,
We have not seen too many issues for either of these carriers. Just the normal processes. You just want to make sure you are diligent with medical records and all other data.
What specific issues are you running into?
Is there a specific revenue code that is associated with HCPC code 90853? We are using 0915 however, most payers are requesting that the rev code is changed to 0905, isn’t that when the patient sees the physiatrist not the LCSW?
Lyn, We normally only see the rev code 0915 used with 90853.
Revenue code 0915 is used for group therapy.
Revenue code 0905 is used for intensive outpatient psychiatric services.
Thank you so much Peter, your knowledge and willingness to share and help others is so appreciated.
Thank you so much for being so helpful. I do have a question that has to do with insurance repricing a claim and assigning an APC 5823 to a 0906/H0015. Have you had any experience with that? They are doing it to all of our claims and creating much larger balances for patients to be responsible for.
Melissa,
We have not seen this done or have been needed when submitting for PHP/IOP behavioral health. It does seem this could create larger patient responsibility from what Medicare is explaining.
What are APCs? APCs, or “Ambulatory Payment Classifications,” are the government’s method of paying facilities for outpatient services for the Medicare program.
APCs, or “Ambulatory Payment Classifications,” are the government’s method of paying facilities for outpatient services for the Medicare program. A part of the Federal Balanced Budget Act of 1997 required HCFA (now CMS) to create a new Medicare “Outpatient Prospective Payment System” (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as “Diagnosis Related Groups” or DRGs. This OPPS was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals and have no impact on physician payments under the Medicare Physician Fee Schedule. APC payments are made only to hospitals when the Medicare outpatient is discharged from the ED or clinic or transferred to another hospital (or other facility) not affiliated with the initial hospital where the patient received outpatient services. If the patient is admitted from a hospital clinic or ED, then there is no APC payment, and Medicare will pay the hospital under the inpatient DRG methodology.
Can RC 1002 be billed with H0015? Please explain
Curious and what not…
Revenue code 1002 typically represents “1002 – Residential treatment – chemical dependency.”
Revenue codes are used in healthcare billing to categorize the type of service or item provided during a patient’s stay.On the other hand, H0015 is a Healthcare Common Procedure Coding System (HCPCS) code. In this case, H0015 represents “Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education.
Whether you can bill revenue code 1002 with H0015 for insurance depends on the specific policies and requirements of the insurance company you are dealing with. Each insurance company may have its own billing guidelines and reimbursement policies.
However, you would be billing a residential rev code with an IOP HCPCS code, which would be not the ideal situation and would probably be denied.
Hello, For IOP we typically see the patient for Group 3 days a week/3hrs each of those day. Then at least once a week that patient is seen for an additional 45min 1:1 session. This is sometimes scheduled on a different day than the Group IOP sessions. We bill H0015 or S9480 on the Group days depending on DX. But can we bill for the Individual on a separate day? And if so, then what CPT/HCPC do we bill?
And from the responses above, it seems if we see the patient for that 1:1 on the same day as a Group 3hr session, we should not also bill for that individual because we already charge a per diem code, is that correct? Appreciate the assistance.
Lindsay,
If individual session is on a separate day from IOP, then you should be able to bill 90834- Individual psychotherapy, 45 minutes. This would be a professional claim.
Just some clarification—all these services are rendered in a hospital based facility by a therapist. We bill strictly on a UB04 claim form. If we should not charge for the additional 1:1 on same day as IOP sessions because its all considered in the Per Diem, would billing the 1:1 on a different day be “over billing” in any aspect?
How can a psychotherapist (outpatient office) bill for an “IOP light” program (1-2 session per week, 3 hours each session) for an adolescent? Thanks!
AEM,
Great question, where are you seeing insurance have a code for an “IOP Light Program”?… each carrier will generally have a single code for IOP, there is normally not an option for a reduction in clinical care at this level – adolescent or adult.
Would a residential treatment facility bill UB claims with a revenue code 0911 for daily treatment without a HCPC code?
Mary,
This would depend on what the carrier requires for billing and the specific type of treatment the RTC is providing.
Which carrier is this question regarding?
California Medicaid stating residential substance abuse rehabilitation should be billed as inpatient.
Mary,
To follow up, different medicaid plans classify residential and inpatient differently depending on the facility and area, etc. This could be the case if that is what information you received back.
Mary,
Carriers vary on whether or not a rev code and HCPC code are required. Sometimes it is just the rev code. It would be good to check the contract/credentialing language specifically.
Hello!
I have been doing hours of research for my company I just started working for a month ago. They just took over their billing from a billing agency and they are struggling billing their DBT/IOP services, particularily group.
SO here in Minnesota, our Medicaid and most commercial plans pay on code H2019 for DBT, including both individual and group DBT (distinguished between the 2 by using modifiers, and occasionally a -59 modifier if they do group and individual DBT on the same day)
BUT we are having trouble with a few insurances that do not accept/pay on H2019. For those plans we tried using the S9480, which, a few of them did accept that code. Great. BUT we have a few remaining plans that we have had to resort to billing a 90853 which as we all know has very minimum reimbursement rates compared to a H2019 or S9480.
Our DBT services are provided as a 2.5 hour long session, but typically on a weekly schedule and some patients do 2 times a week. So the issue is that we don’t meet most pre-auth requirements for a S9480. There are a few other codes I have came across, H2014/H2015 but those seem to be alcohol and drug related, which we aren’t focused on (some clients yes but that isn’t the main focus of our groups).
Does anybody have any suggestions at all???
One other thing I have had trouble with is billing same day services – namely, the group and individual DBT sessions that some clients will have on the same day. Different times, different providers, etc. Many plans accept the 59 modifier but I have a few that don’t seem to accept it – Cigna, UMR, Anthem BCBS are the ones I struggle the most with.
Has anyone ever tried using the newer XE modifier? Or is it Medicare specific?
I know that was a lot to unpack so if you read through all of that THANK YOU THANK YOU THANK YOU!! Any suggestions will be super appreciated!
Cassie,
Thank you for the deatailed inquiry. A lot to unpack there.
Normally S9480 will require some type of pre-notification or authorization and usually it requires 3 hours of clinical services per day and 9-15 hours per week.
As far as same day services, even with a modifier, insurance often denies multiple on the same day. So it is good to set up programming and billing for the daily IOP rate.
Normally outpatient mental health is billed 45 min or 60 min sessions.
90834
90837
90847
90853
90871
etc.
What would be the appropriate HCPC code to bill for a patient in an IOP admitted on a Friday for the week? Does the weekly hours jump to the following week? If the hours do not move to the following week, how would this be reported?
Mary,
Good question.
As long as the patient met the required hours for what the carrier requires for IOP, you can bill for that end of the week day. Each week does not necessarily start on a Monday.
For IOP in general, if a patient admits any time during the week, the general minimum 9 hours a week… and that’s scheduled program hours.
Thank you for the response. The patient was admitted on the Friday and 3 hours were spent in counseling for the week. This does not meet the 9 hours. DHCS defines the program week as Sunday to Saturday. Is there another HCPC or CPT code that can be used for this one day?
Mary,
There is not another code, we would recommend checking with the auth department at the carrier, or your contracting rep to see if you can bill for that day. Otherwise, it could be possible to bill for the ind/fam/group therapy that day if the plan allows for each session with a modifier.
We use 90791 for assessment on admittance to our IOP services
For an IOP is there a code you can bill when discharging a patient from the treatment program ? (Medicaid KY)
Danny,
There is not a discharge code, if the patient receives services that day for IOP you can bill for that. Or if there is an assessment done with a licensed clinician for discharge or therapy, you could bill for the individual outpatient services.
We are an outpatient facility that bills IOP on a UB form. Can the providers bill professionals codes on a HCFA for their services. It would be 2 different tax id #’s
Yes, you should be able submit HCFA as a provider with professional codes. You may just need to add each treating professionals NPI to the respective date of services/claims.
If a RTC is billing a per Diem code, say H0018 or S0201 and they send out the lab (urine Drug tests and/or Covid testing) to an independent Lab is it appropriate for the lab to bill for those services or are they considered inclusive to the per diem code and should the lab bill the facility for those dates of service seeing’s the facility is getting paid for Per Diem ?
Sophia,
Good question. Most plans require UA billing / services be included in the per diem RTC rate. There are some plans – sometimes medicaid that let you break them out. For the most part, these are included though.
Can both T1016 and S9480 services be billed on the same day?
Ivellise,
Sometimes these can be billed together with medicaid plans. It is unlikely that any commercial carrier would allow for these on the same day.
can the following be billed together – was in the following year 2021 through May 2022
H2027 16 units/ 4 hrs
H004 HQ 8 units/2hrs
H2014 8 units/2hrs
total 8 hrs
typically billed 8 hrs per dy, 5 days a week
then switched to H0015 in May 2022
Kathy,
Who were the carriers you were wanting to know if those codes could be billed for? And what state? There are some variables.
I found out that in AZ billing IOP H0015 and H0004 Group Behavioral Health Counseling and Therapy is allow. Are you aware of this? If so, Does billing 3 hours of H0004 looks excessive?
Sylvia,
H0004 is normally billed in 15 minute units and the maximum allowed per day can vary depending on the plan, this would be something you would want to check in each patients benefits. H0015 is per diem and H0004 is a specific timed service. Again, lots of variables here.
Hi,
I have a few questions about PHP and IOP billing I’m hoping you can help with:
1) The typical language I see states a 20 hour/week requirement. However in conversations I’ve had it with other billers it sounds like there is also a 5 hour/day requirement. Is there a source for a daily requirement for PHP Billing?
2) Can PHP or IOP services be provided and/or billed on the weekend. As an example if a client missed their groups on Monday for a medical need, can we provide them with 5 hours of services on a Saturday and bill Saturday instead of Monday for that week?
3) Our outpatient program is a freestanding facility but it is licensed as an integrative clinic and can provide medical services. Is there any issue billing for a medical follow up on the same date that the PHP or IOP per diem is billed? Its my understanding that medical services would be separate than the BH services provided under the PHP or IOP programs and should therefore be allowed, but was curious if thats what your experience has been
Hi,
I have a few questions about PHP and IOP billing I’m hoping you can help with:
1) The typical language I see states a 20 hour/week requirement. However in conversations I’ve had it with other billers it sounds like there is also a 5 hour/day requirement. Is there a source for a daily requirement for PHP Billing?
2) Can PHP or IOP services be provided and/or billed on the weekend. As an example if a client missed their groups on Monday for a medical need, can we provide them with 5 hours of services on a Saturday and bill Saturday instead of Monday for that week?
3) Our outpatient program is a freestanding facility but it is licensed as an integrative clinic and can provide medical services. Is there any issue billing for a medical follow up on the same date that the PHP or IOP per diem is billed? Its my understanding that medical services would be separate than the BH services provided under the PHP or IOP programs and should therefore be allowed, but was curious if thats what your experience has been
Daniel,
1) Normally PHP can range from 4-6 hours a day and there are a variety of ways to meet those hours. The weekly requirement can vary as well depending on the carrier. You would want to determine the exact requirements when requesting authorization up front for each patient.
2) PHP and IOP can be billed on any day as long as the per diem hours are met by each carriers/plan criteria. Normally insurance will be ok with weekend services, but it is always best to check up front. They will mostly ask what your programming is and determine if you meet their criteria, not the other way around.
3) Normally PHP/IOP can be billed on the same day as a medical service, but it would depend on the medical service – if it is medication management then this would sometimes have to be included in the per diem day for PHP/IOP. This also depends on medicaid/medicare vs. exchange or private plans.
Hello,
We have an IOP Program in Nevada. We had a PT that did not stay for the hours required to bill S9480. He was only in session 1.5 hrs. The code we billed was 90853 but this of course is minimal reimbursement. Is H2019 with the revenue code 0915 but minus the time span a G0410 & G0441 seem to be the closest to what we are looking for. The 90853 just doesn’t seem to suite the situation the best.
We are currently having issues getting paid for IOP for our providers. We have been billing 99214 with POS 22 for a while now for our providers who are Psychiatrists that see patients in an IOP program in the hospital. We usually have no issue getting paid but recently we are getting denied and being told by insurance companies that we are billing IOP wrong, even though they had paid previously. The hospitals the patients are being seen at are telling us that IOP is no inclusive, so we wouldn’t be billing per diem? We get authorization for IOP for our providers, but the authorizations don’t have any CPT codes attached to them.
Stevie,
Each plan can treat IOP differently as far as what is included per diem and what isn’t. 99214 is more of a patient office visit then a per diem IOP day. We have not used that code to bill for IOP MH or SA. Normally IOP consists of 3 hours of group/ind/fam therapy combined together for the day. An outpatient visit would not be a per diem code such as S9480 for mental health.
Sometimes patients can get mixed up with outpatient vs. intensive outpatient. There are other codes to use for IOP in a hospital setting. Depending on if it is medicaid/medicare, exchange, or private insurance, these codes and modifiers could vary.
Do you have any experience in billing claims for IOP to Health Net of California? I need the HCPCS/CPT code for IOP and the revenue code. Thank you!
Hello,
We have submitted claims to Health Net of CA previously, processes on the insurance side can change all the time. Is this for mental health or substance abuse IOP?
Hi,
We have a group practice in Ohio that has MDs, NPs, and LISWs and we are trying to expand to provide IOP services as well. We are running into some issues with how to bill S9480 in an office place of service. Aetna told us to re enroll as a facility because IOP is “inpatient,” but then denied the application because our NPI is for a group practice. Does it just depend on the payer if they’ll accept IOP in an office? Also, do we need to be accredited by joint commission to provide IOP? Any advice would be helpful. Thanks!
Hi! I am hoping this page is still being monitored. I see replies up to Jan 2024 but nothing after.
I have been consulted to do billing for a mental health practice that specializes in substance abuse. I am familiar with CPT coding the most. Many years ago I did DME billing so I am a little familiar with HCPCS and did a short stent in a SNF so I am a little familiar with UB04 claim forms. All of that to say I need a little guidance and direction.
This clinic is for starters just doing outpatient therapy. I don’t know if they plan on keeping the outpatient office, but I do know they are working on getting a license to do inpatient treatment.
So the breakdown to my questions are:
If they are just providing 1:1 sessions but are substance-related am I looking more towards HCPCS codes such as H0004 (or would it be H0015?), or am I looking at CPT coding such as 90832 POS being 11 (office). I will have to ask them if they are doing group therapy to adjust the coding. Would I be using either HCPCS or CPT pending insurance regulations? Is one more favorable over the other?
I have read up on the IOP coding mentioned many times in the above questions. I thought I saw one question mentioning something about being licensed for IOP’s. Is that a separate, needed license for a practice/provider? Can these IOP services be provided in their office setting? I will be working on credentialing this practice and the providers as they hire, along with learning all the services they plan to provide. It’s gonna be a fun time!
Hi, first of all, I really appreciate your great help for all of us.
I am working with a behavioral facility in Nevada, and we are not getting paid for IOP services like all H and S codes from any of the insurances, neither Medicaid nor Medicare.
Initially, we were getting denied as the services required preauthorization, then we billed future claims with prior authorization, but still, the H&S codes are getting denied due to multiple other reasons, including that we have taken the authorization for our facility and not for the rendering provider, but we are using our facility tax ID for billing. I have read almost all of the comments and your replies, so my question to you is, are there any other CPT codes we can bill instead of H&S codes, and can we bill the same code to Medicaid and Medicare?
Also, do we need to bill on UB04 for commercial insurance? And can this code 0905 be billed if these codes H0015 or H0038 are getting denied ?
There are some medicaid/medicare plans that do not allow for H or S codes and everything has to be done on a professional claim – all 9 codes, which would reduce reimbursement significantly. The possible other issue is incorrect modifiers. If there is a contract you received you can start there for specifics, or look at the Nevada guidelines for medicare/medicaid reimbursement and there might be some direction on codes and modifiers there that pertain to your facility.
On commercial insurance, you would need to bill on a UB04 for H0015. The rev code would be 0905 and HCPC would be H0015. H0038 would normally be on a CMS 1500, however sometimes commercial insurance deems that included in a per diem code and you can’t separate it.
Thank you so much for all your help. My question is Medicare denied our claim in South Carolina for HCPCS code H0015. what we can bill to Medicare in replacement of H0015.
Was this done on a professional claim or institutional claim? It depends on if it was a claim submission error or some network issue. What was the reason of the denial? Usually there is a code that can help give insight on how to fix it and get reimbursement.
CPTHCPC Code H0006 not accepted with Rev Code 0945 and 0900 by BCBS AR is their any alternative code which we can bill so that they accept the CPTHCPC code and Rev Code.
Ayesha,
Is this a medicaid BCBS or commercial? Are you in or out of network? Does the plans you normally work with have this benefit or require some sort of modifier with it depending on the credentials of the rendering provider? There are some variables here!
This is such a great resource, thank you for these blog posts and comments!
One thing I am noticing more of in the field is the idea of allowing both IOP and PHP or IOP and OP patients to attend the same groups. So for example, both the PHP patients and IOP patients would be in the same group at the same time, facilitated by the same provider, etc… the PHP patient would be billed for PHP and the IOP patient would be billed for IOP. Is it okay to bill this way? It seems like it wouldn’t be okay, since these are different levels of care, with different eligibility criteria, etc.. but I’ve heard of a few different facilities in different states doing this. I’d appreciate any insight you can share, thank you!
Hello,
Hello,
We have not come across this issue previously.
Normally insurance authorizes reimbursement of the level of care by the hours per day/per week and the medical necessity of the patient as criteria, not whether these groups would possibly be mixed. This would be plan dependent and more of a clinical specific issue, rather than if insurance allows for it to be reimbursed or not. Because programming is normally very specific to the individual, these groups do not usually cross over. Higher levels of care usually mean more acuteness of symptoms and programs and facilities will naturally separate the patient base.
You would want to check with each carrier and plan to see if this is an issue.
We are not a doctors office or a hospital. We are a facility that provides SUD services. Is there anything that Medicare will reimburse for our type of facility?
This depends on your licensure and if you are able to be contracted with Medicare. Can you provide specifics?
What would I look for as it relates to our licensure that we would need?
William, You would want to see what governing body issues behavioral health licensure for your level of care of your facility.
Then you would need to contact Medicare credentialing to see what the requirements are in order to get in-network.
We consult on this sort of thing, it is just time consuming.
We are a rural health clinic in Kentucky. We provide substance abuse IOP 3x weekly at 3 hours per class and bill KY Medicaid. My question is this: what if a client misses one of the classes for a sickness or emergency, can you still bill the other 2 classes out as IOP? Or what if one of the classes lands on a holiday and you only have 2 classes that week, can you still bill those 2 out as IOP? What do you do when you end up only having 2 classes (6 hours) for that week, whether due to the client missing for whatever reason or being closed because of holidays?
I am having the same issue as Dawn Swimmer was with ChampVA due to Condition Codes, occurrence codes and value codes. They are denying our behavioral health PHP (partial hospitalization) claims and our IOP claims for the same reason. We also use bill type 13X and we have attempted to bill for Condition code 41 (to indicate PHP). I’ve tried many variances using codes that could apply to the client but there’s nothing anywhere that guides you to what they are looking for or what is required with their billing. Very frustrating to say the least. I’m wondering if Dawn was ever able to resolve her claims. If so, could she please reach out to me & give me some direction?
Hello All,
We are a very small, independent, tele behavioral health company. I need to know if we can bill 90837 – Psychotherapy, 60 minutes with patient and/or family member and H0031 – Mental health assessment, by non-physician, on the same date with the same provider. Since we perform both tasks at the same time. Thank you.
For IOP, if a patient is seen for 3hrs on day 1 and 2 but only 2hrs on day 3, how do we bill overall since we are under the required 9hrs per week?
Do we stepdown this patient for the week and addend the codes and bill outpatient codes instead of per diem IOP?
Lindsay,
That is a good question and technically you would be good to bill as long as you are meeting the 9 hours a week for IOP. However, for some carriers, they require both the 3hrs per day as well as 9 hours per week. You would want to call the patients claims or auth department and clarify.
I just joined this practice and found issues where IOP/PHP and RU claims processed on CMS1500 are denying for incorrect place of service. We have rebilled claims according to the setting with 02,52,55,57 and claims are still denying. What other factor could cause claims to deny for POS? Example: Scott and White payor F33.2 Dx, 99214 CPT w/ MOD 95 for IOP services billed with POS 52 denied for POS. Example: Aetna payor F31.4, F16.20 and F10.20, CPT 99232, POS 51.
E,
Thank you for the descriptions and examples. The other factors could be a variety of issues similar to the previous question by tricia.
Normally commercial policies require per diem claims to be on a UB04 institutional claim form. This could be your POS issue.
Is this for Medicaid/Marketplace/Commercial type of plan? Both Baylor Scott and White as well as Aetna I believe have MCO options for medicaid/medicare plans. For PHP/IOP, it may be beneficial to use revenue code 905. This could also be a credentialing issue, a network/plan issue, a clinician not having the correct licensure as rendering provider – or billing provider. Also the plan could require IOP to be billed as an institutional claim.
Again, this could be a simple fix or something a bit more complicated.