CMS releases IOP requirements for FQHCs and RHCs

CMS recently outlined billing, coding, and plan of care requirements for Intensive Outpatient Program (IOP) services for Federally Qualified Health Centers (FQHC) and rural health clinics (RHC). These requirements took effect January 1.

IOPs are distinct and organized outpatient programs of psychiatric services furnished to patients with an acute mental illness. CMS will pay for IOP services at the same rate as if they were provided by a hospital.

The agency noted that certain IOP services are not payable as RHC or FQHC services. For example, although group therapy is considered an IOP service and payable via the IOP payment amount, it would not be paid if billed as an RHC or FQHC service.

The RHC IOP services payment rate is based on the three-services per day hospital-based per diem payment amount, which is $259.13. For FQHCs, the payment is based on the lesser of its actual charges or the previously mentioned per diem payment amount.

Providers should report condition code 92 to identify intensive outpatient claims and revenue code 0905 when billing IOP services, according to CMS. The agency previously released billing requirements for condition code 92.

CMS listed all IOP codes and services in the transmittal. At least one IOP service from List A must be included on the claim for payment, and any additional IOP services from List B on the claim will be bundled for that specific day.

For coinsurance calculation purposes, RHCs must report the CG modifier on the line for payment along with the charges, according to CMS. FQHCs must report charges on the primary service line for all IOP services furnished that day.

IOP services must be provided as part of an individualized, written plan of treatment that is periodically reviewed, according to CMS. This treatment plan, which should be reviewed no less than every other month, requires the following:

• The physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan
• Physician certification that an individual needs IOP services for a minimum of nine hours per week of therapeutic services as written in their plan of care

Revenue integrity professionals at an RHC or FQHC must ensure their organization is aware of IOP billing, coding, and plan of care requirements.

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