Closer Look At IOP Billing For Behavioral Health Service Providers

Billing for IOP in a nutshell

Are you seeing changes in IOP billing for mental health in 2021? 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.

  1. Hospital-based inpatient programs, that require medical monitoring, nursing care, and other behavioral health services treated 24/7.
  2. Residential treatment programs, also known as RTC, which is more of a sub-acute facility based monitoring, offering other behavioral health services.
  3. Partial hospital programs, better known as PHP, providing services in an ambulatory setting, and generally requires 20 hours per week.
  4. 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:

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.

47 thoughts on “Closer Look At IOP Billing For Behavioral Health Service Providers

  1. I am trying to bill for iop for mental health. Allowable rate came back $37 from BC. I used code S9480 and 1unit. This doesn’t seem right for 4 hrs per day. Any advice on how to bill and get paid correctly is very much appreciated. We just started the iop program.
    Thank you

  2. Can a facility that offers IOP and RTC and detox services conduct groups with all 3 levels together and bill for it???

  3. Can all IOP services be billed under the Physician that oversee the program or does that provider have to be present during each of the services. Group, Individual etc

    1. Hey great question!

      IOP can be billed under the medical director or whoever is running the services as long as it is a LCSW or higher. However we are starting to see some changes in some plans not allowing the NPI of the physician that oversees the IOP. It can change from plan to plan.

      Thanks, let us know any other questions!

  4. Can we bill for other services like Individual Therapy or Crisis Therapy on days that the patient is not attending the IOP session?

  5. We are billing IOP but sometimes the patients don’t complete the 3 times a week treatment. They may only get in 2 days that week. Can i still bill IOP if we dont have at least 9 hours for that week?

  6. That is a good question and something that happens often. It really depends on the carrier/plan criteria for IOP. However, normally plans are based on the program, not the patient attendance. The program runs 3 days per week for 3 hour sessions… there will always be intermittent billing with clients missing days. This is why authorization approvals may be for 13 visits in a 60 day window.

  7. Hi, I’ve been billing out our IOP claims on a HCFA1500 form, but I just got a denial from Blue Cross stating that all IOP claims have to be billed on a UB04 claim form. Is this correct? I’ve had no problem getting paid from Blue Shield, Aetna, Cigna, United Health Care. Blue Cross is the only insurance company saying this.

    1. Yeah we see this all the time with BCBS. They go back and forth on IOP in using a 1500 or a UB04. Sometimes the only way is to submit the UB04 and see if that pays or if you get some other erroneous type of denial.

  8. Can a newly-established IOP / PHP bill insurance companies for services prior to being accredited by CARF or Joint Commission (i.e., will insurance companies contract with an IOP / PHP before it’s been operational for the required 6 month term before a CARF survey is possible)?

    1. Hello there and great question.

      Yes the majority insurance companies do not require accreditation on an out of network basis. It just depends on the plan so you would need to check up front. You can also get a temporary approval if insurance requires it. Will you be trying to go in-network?

  9. Hi! We are trying to determine coding that would indicate a difference between general MH services and ED services since our contracts reimburse differently for each of the lines of service. Are there additional codes that can be used for MH or are the alternatives all indicative of substance abuse care?

    1. This is a great question that has some variables for an answer. We help a lot of ED facilities. Someone from the team will reach out via email.

      Thanks!

  10. I understand that IOP Programs can be individual or group. However, our particular IOP Program is provided through group sessions, 3 hours per day @ 3 times per week. Due to Covid, our caseload has decreased, meaning we currently only have a few patients enrolled in our IOP Program. Can H0015, IOP, be billed if only one person was present in the session?

    In regards to your article above noting services typically covered in IOPs, can an individual or family session be billed on the same day as an IOP session, if the session was separate from the IOP session?

    1. This depends. Is this primary substance abuse or mental health?

      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 would be for IOP depending on DX codes.

      Please send text t0 541-ASK-AXIS for further clarification.

      1. Because I previously replied via email, I wanted to add it to this discussion page.

        As I stated in the reply, the service is for SA IOP services, billed using H0015 or Rev. Code 0906 for non-Medicaid payers.

        The answer I received was that H0015 can be billed no matter how many people attend the session.

        Also, there was a 2nd question to my original inquiry:
        If a patient is enrolled in SA IOP, can a separate individual or family session (H0004 or H0005) be billed on the same day as an IOP session (H0015)?

        Thank you!

        1. Correct, H0015 can be billed no matter how many people attend.

          Billing and individual session on the same day of IOP will depend on if the plan allows for that. You can always submit the claim with a modifier, however you risk both claims denying for duplicate billing.

  11. I’m not getting any luck billing Blue Cross of CA. for our IOP program on a 1500 form with a place of service 53 and HCPC code of S9480. They are rejecting me stating that my S9480 code is not pricing. S9480 is a valid code that other insurance companies pay with no problem. We are out of network and they won’t give use a single case agreement so we can specify which codes we will be billing with. The patient has out of network benefits, 60/40 policy but they won’t pay us due to the S9480 code. Is the only way to get paid is by billing on a UB04 claim form? Can I bill on a UB04 form if this patient was never in the hospital? Some of the mandatory places to fill out on a UB04 claim form are admit date, discharge date.. etc.

  12. Can H0015 be billed on a professional claim without the rev code? We bill medicaid this way all the time but I am trying to bill Blue Cross and they are saying that H0015 is not a recognized code. I’m seeing all of the H0015 on a UB04 with a rev code but never on a professional for commercial

  13. Where can I find the rule that defines who is responsible for IOP supervision for Billing, i.e. can an LPC be the IOP Director while the LMSW or LCSW be the counselor? I am trying to hire a program director for the IOP but cannot find who is specifically is supposed to run the program.

    1. Hello,

      Great question. Although this usually depends on the state and the insurance plan policy if you are trying to get reimbursement, as long as the Director is a licensed therapist – it does not matter if it is LCSW or LPC, etc.

      Please text us at 541-ASK-AXIS for further clarification.

  14. Can non-licensed therapists run groups if they are under supervision? If so, does the supervision have to be “in-house?”

  15. Can a non-licensed therapist run groups or do individual sessions in an IOP if under supervision? If so, does the supervision have to be “in-house?”

    1. No, the therapy needs to be done by a licensed clinician in order for insurance to be reimbursed.

  16. This is normal for California, as they have split the BC/BS and BS = Blue Shield process the professional claims, & the Blue Cross process the Facility charges

    1. IOP is normally filed as institutional only. The initial assessment can be done as professional, but the daily IOP claims are institutional.

      Is there a particular insurance carrier this is for?

  17. Hi, My business provides SUD Outpatient services in the state of Washington. We do not offer MH at this time. I have a billing provider I have contracted with. They have told me that because I do not have a doctor on staff that we are not a facility. And because we are not a facility we cannot bill using H-Codes. We do have a Licensed SUDP clinician. The codes that are currently being billed are paying us $15 per a 3 hour IOP group. This doesn’t seem right to me. Is it true that we can’t use H-codes? What in the above info doesn’t make sense to you?

    1. This doesn’t seem right to us either. You do not need a doctor on staff to be considered a facility, every state has different requirements just like every insurance carrier does. $15 per group is lower than medicare/medicaid rates and does not make sense.

      This might be worth a conversation. There are definitely options here for you to increase your reimbursement at no extra cost.

      Feel free to text us at 541-ASK-AXIS for a more immediate response or just give us a call. 888-623-5535.

  18. I have a provider who is the provider over IOP and PHP for a hospital and having trouble getting him paid with Magellan and Amerigroup… Could you share with me what code to use?? We have used everything and still no luck getting him paid.. We get all other insurance paid but not these two insurance. Thank you

    1. This might be easier to do over a call. The codes are not super complicated although the modifiers could be depending on the exact setting.

      Text us at 541-ASK-AXIS For an immediate response.

  19. Can Residential clients who are asam level of care 3.1 attend the same family group therapy as an intensive outpatient asam level of care 2.1 and the services be billable?

    1. This depends on a few things. Depends on the insurance and network and state licensure as well as program structure. The answer is yes and no. Feel free to contact us at 541-ASK-AXIS and we can further answer your question.

  20. We are OON with MHN and they are denying our SA IOP claims stating that 0906 is a precluded REV code due to our being outside network. My question is, can an insurance company dictate what level of care can be billed like that? The REV codes that they do authorize for OON providers has a substantially lower reimbursement, so I feel like they are almost trying to force us INN just so that we can be paid what we are billing for. Has anyone else had this happen, and if so how did you address it? I have a call in right now to a PR to see if maybe we can get around this with a SCA, but I am not holding out a lot of hope.

    1. This is common for insurance companies to dictate the type of code depending on the plan and policy and the benefits for services in how claims are paid. It can be seen as a tactic to get providers to go in-network for sure. Insurance companies have specific allowable amounts and sometimes the payment is very low. You do have options to ask for at least the national average for the given level of care. There are no guarantees carriers will do anything, that is probably why there so many class action lawsuits.

  21. Can an IOP therapist help a co-worker whom is another therapist, by assisting with discharge and treatment planning responsibilities? If so, what explanation can you provide please to justify this sharing of duties? The therapists are use to billing under their own NPI number at other employers and struggle to understand the structure that IOP does not bill by specific IOP therapist provider.

    1. Hello,

      Thanks for the question.

      It can depend on the insurance company, but collaboration is normally encouraged in any treatment planning. As long as the both therapists are licensed this is fine. Just bill under the group NPI and add the primary therapist treating NPI if needed.

  22. I see above that accreditation is not required for IOP billing with code S9480. Is a state facility license required for reimbursement? When conducting vobs I sometimes see the language added, “state license required” and sometimes this is not indicated. Is it ever ok to bill and collect for S9480 without a state facility license?

    1. Sarah,

      Great questions.

      It really depends on the individual plan policy and what it allows. However, almost every plan does require at least state licensure for S9480 IOP. The question you would normally want to clarify is if accreditation is required along with the state licensure.

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