Final CMS regulations name occupational therapy as a core benefit in Intensive Outpatient Program for mental health services
When Congress unveiled a massive $1.7 trillion omnibus legislative package in December 2022, it included multiple provisions to strengthen mental health services, including a new Medicare mental health benefit: intensive outpatient services to be provided by hospitals, federally qualified health centers (FQHCs) or rural health clinics that could significantly increase the ability of occupational therapy practitioners to provide community mental health services.
Currently, under Medicare, there is a "partial hospitalization" (PHP) mental health benefit for beneficiaries who require 20 hours a week of mental health services provided in an outpatient setting. Occupational therapy is a listed service in the partial hospitalization law, and regulations require that anyone receiving partial hospitalization services be evaluated to determine whether they need occupational therapy services and, if so, that they receive them.
The new intensive outpatient program (IOP) benefit mirrors the PHP benefit, although it would apply to an individual who only needs 9 hours of services per week (compared to 20 hours in PHP) to qualify. All of the mental health services included in the benefit, including occupational therapy, remain the same. FQHCs are traditionally paid using a pre-established bundled rate; however, the intensive outpatient services will be paid separately at the same rate as if they had been provided at a hospital outpatient department.
The Centers for Medicare & Medicaid Services developed proposed and final regulations through the CY 2024 Medicare Hospital Outpatient Prospective Payment System (HOPPS) Proposed Rule governing intensive outpatient services. AOTA is excited to announce, after significant advocacy, that the CMS final rule names occupational therapy as a core IOP benefit. The IOP and related services will be effective on January 1, 2024.
Coding and billing IOP services under the OPPS
CMS has approved a new condition code, 92, to identify intensive outpatient claims. Thus CMS will require hospitals and CMHCs to report condition code 92 on claims to indicate that a claim is for IOP services and will continue to require hospitals to report condition code 41 for PHP claims. Under both IOP and PHP, occupational therapy services can be billed using HCPCS code G0129; AOTA is currently seeking clarification from CMS regarding whether OT practitioners can bill any CPT codes, in addition to G0129, under the IOP.
This is an exciting new opportunity to provide occupational therapy mental health services in the community.
Questions? Contact the AOTA Regulatory Affairs team at regulatory@aota.org.