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.
- 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.