CMS releases billing requirements for new condition code 92

Wednesday, January 17, 2024

CMS released billing requirements for new condition code 92, which identifies claims for Intensive Outpatient Program (IOP) services and became effective on January 1.

IOPs provide treatment at a more intense level than psychosocial rehabilitation or outpatient day treatment, but a less intense level than a partial hospitalization program (PHP), according to CMS.

Patients admitted to an IOP must meet the following criteria:

  • Under the care of a physician who certifies the need for IOP services
  • Requires a minimum of nine hours of service per week
  • Requires comprehensive, structured treatment with medical supervision due to a mental disorder (including substance use disorder) that severely interferes with multiple areas of daily life
  • Able to cognitively and emotionally participate in the active IOP treatment process

IOP services will get per diem payments under the Outpatient Prospective Payment System (OPPS) when billed by an OPPS provider, according to CMS. These requirements apply when IOP services are provided by hospital and critical access hospital outpatient departments, as well as community mental health centers.

CMS noted that Medicare Administrative Contractors will return an IOP claim if it overlaps PHP claims with condition code 41 or has a line item date of service within seven days prior to the “from date” for an incoming claim for the same patient and provider.

Revenue integrity professionals who work at one of the aforementioned provider types should review these billing requirements and ensure their organization is in compliance.

Editor’s note: Find more NAHRI resources on IOP services and 2024 OPPS changes here.