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, state insurance agencies nor insurance carriers do not have a requirement.
Here is what we will try to answer:
1. How many patients are allowed to be in PHP/IOP together?
2. Is reimbursement higher for per diem or per session?
2. Can S9480 ever be billed on a CMS 1500 without the revenue code or must it always be on UB04?
3. A little clarity on how to bill using the S9480 code…for example if a program had 3 patients in treatment and they met for 3 hours a day 3 days a week. What would that look like in terms of insurance billing?
There are a lot of variables to insurance billing, each policy of a plan needs to be vetted and checked for limitations and criteria
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 individual, family, group therapy (90837/90847/90853) because it’s per diem and these codes add up to the same clinical hours to be about 3 hours a day, reimbursement is sometimes equal. Many insurance carriers do not allow for multiple services for therapy to be billed on the same day regardless of modifiers that can be used to specify this. Providers must bill for the actual services provided essentially.
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.
Insurance carriers often are not allowed to inform providers how to bill or which codes to use, unfortunately.
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 insurance carriers that require S9480 (which appears to be a Healthcare Common Procedure Coding System code for PHP/IOP 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.