What is the Limit for Number of Patients for a PHP or IOP Behavioral Health Treatment Program?

The specific number of patients allowed in either a Partial Hospitalization (PHP) or 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. Generally, neither state insurance agencies nor insurance carriers impose such a requirement.

Here is what we will address:

1. How many patients are allowed to be in PHP/IOP together?

2. Is reimbursement higher for per diem or per session?

3. Can S9480 ever be billed on a CMS 1500 without the revenue code, or must it always be on a UB04?

4. How do you bill using the S9480 code? For example, if a program had 3 patients in treatment who met for 3 hours a day, 3 days a week, what would that look like in terms of insurance billing?

The capacity and census of a PHP/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 PHPs/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.

Although the reimbursement rate for IOP (S9480) should not be the same as that for individual, family, and group therapy (90837/90847/90853), because S9480 is per diem while those per-session codes add up to roughly the same three clinical hours a day, reimbursement is sometimes equal. Many insurance carriers do not allow multiple therapy services to be billed on the same day, regardless of the modifiers that could be used to specify them. Ultimately, providers must bill for the actual services provided.

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. It is unlikely, but there could be a published list of those requiring S9480 be billed HCFA/CMS 1500.

Carriers change billing requirements often, and finding up-to-date information on specific insurance carriers and their billing requirements can be challenging. 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 which insurance carriers require S9480 (the Healthcare Common Procedure Coding System code for intensive outpatient psychiatric services, per diem) to be billed on the CMS-1500 form, we can help, and we recommend reaching out to the specific insurance companies or consulting the provider manuals and billing guidelines those carriers publish.