Psychiatric Intensive Outpatient Programs

Description of Procedure or Service

Psychiatric Intensive Outpatient Programs (IOP) provide time-limited, multidisciplinary, multimodal structured treatment in an outpatient setting. IOP is intended to provide treatment on an outpatient basis, does not include boarding/housing and is intended to provide treatment interventions in a structured setting, with patients returning to their home environments or a community-based setting outside of program hours. Intensive outpatient programs do not include treatment in a locked unit or restricted access setting.

Related Policy:

Psychiatric Partial Hospitalization Programs

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for Psychiatric Intensive Outpatient Programs (IOP) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy.

Coverage for services described in this medial policy may be subject to prior authorization by Blue Cross Blue Shield of North Carolina or its designee.

When Psychiatric Intensive Outpatient Programs (IOP) is covered

Treatment for Psychiatric Intensive Outpatient Programs may be considered medically necessary when members meet ALL the criteria listed below.

1. If required by state statute, the program is licensed or certified by the appropriate state agency that approves healthcare program licensure or certification.
2. There is documentation of drug screens and relevant lab tests upon admission and as clinically indicated.
3. There is documentation of evaluation within 3 treatment days of admission by a psychiatrist or psychiatrist extender who remains available as medically indicated for face-to-face evaluations.
4. After a multidisciplinary assessment, an individualized treatment plan using evidence - based concepts, where applicable, is developed within 3 treatment days of admission and amended as needed for changes in the individual’s clinical condition. Elements of this plan include, but are not limited to subjects such as identification of key precipitants to current episode of treatment, assessment of psychosocial supports available after discharge, availability of aftercare services in member’s home geographic area, potential need for supportive living placement to continue recovery, consideration of the ability of the member/family/support system to meet financial obligations incurred in the discharge plan, need for services for comorbid medical or substance use conditions, contact with aftercare providers to facilitate an effective transition to lower levels of care, and other issues that affect the likelihood of successful community tenure.
5. Treatment programming includes documentation of at least one individual counseling session weekly or more as clinically indicated.
6. Clinical documentation supports the member is evaluated on each program day by a licensed behavioral health practitioner.
7. Licensed behavioral health practitioners supervise all treatment.
8. Mental health and medical services are available 24 hours per day, seven days per week, either on-site or off-site by referral.
9. A Multidisciplinary treatment program that occurs a minimum of three days per week and provides a minimum of nine hours of weekly clinical services to comprehensively address the needs identified in the member’s treatment plan. If the treatment program offers activities that are primarily recreational and diversionary or provide only a level of functional support that does not treat the serious presenting symptoms/problems, Blue Cross NC does not count these activities in the total hours of treatment delivered.
10. When members are receiving boarding services supported by the program, during non-program hours the member is allowed the opportunity to:
    1. Function independently.
    2. Develop and practice new recovery skills in the real world to prepare for community reintegration and sustained, community-based recovery.
11. There is documentation of a safety plan including access for the member and/or family/support system to professional support outside of program hours.
12. Recent treating providers are contacted by treatment team members to help develop and implement the initial individualized treatment plan within three treatment days of admission.
13. Family participation:
    1. For adults: Family treatment is being provided at an appropriate frequency. If Family treatment is not rendered, the facility/provider specifically lists the contraindications to Family Therapy.
    2. For children/adolescents: Family treatment will be provided as part of the treatment plan. If Family treatment is not held, the facility/provider specifically lists the contraindications to Family Therapy. The family/support system assessment will be completed within three treatment days of admission with the expectation that the family is involved in treatment decisions and discharge planning throughout the course of care. Family sessions will occur at least weekly.
    3. Family participation may be conducted via telephonic or virtual sessions when there is a significant geographic or other limitation.

Admission Criteria:

Must meet all the following:

1. A DSM diagnosis is the primary focus of active treatment each program day.
2. There is a reasonable expectation for improvement in the severity of the current condition and behaviors that require a minimum of nine hours each week to provide treatment, structure, and support.
3. The treatment is not primarily social, interpersonal, domiciliary or respite care.
4. The therapeutic supports available in the member’s home community are insufficient to stabilize the member’s current condition and a minimum of nine hours of treatment each week is required to treat the member’s current condition safely and effectively.
5. The member’s current condition reflects behavior(s)/psychiatric symptoms that result in functional impairment in 1 area, including but not limited to:
   1. potential safety issues for either self or others
   2. primary support
   3. social/interpersonal
   4. occupational/educational
   5. health/medical compliance
6. The member is cognitively capable to actively engage in the recommended treatment plan.
7. This level of care is necessary to provide structure for treatment when at least one of the following exists:
   1. Clinical documentation supports that the member requires the requested level of care secondary to multiple factors, including, but not limited to: medical comorbidity with instability that impairs overall health, concurrent substance use disorder, unstable living situations, a current support system engages in behaviors that undermine the goals of treatment and adversely affect outcomes, lack of community resources , or any other factors that would impact the overall treatment outcome and community tenure.
   2. After a recent therapeutic trial, the member has a documented history of an inability to adhere to the treatment plan at an intensive lower level of care, being non-responsive to treatment or failing to respond to treatment with a reduction in symptom frequency, duration or intensity that triggered the admission. Failure of treatment at a less intensive level of care is not a prerequisite for requiring benefit coverage at a higher level of care.
   3. The member is at high risk for admission to acute inpatient care secondary to multiple recent previous treatments that resulted in unsuccessful stabilization in the community post-discharge.
      
      Note: intensive treatment is defined as at least weekly sessions of individual, family, or group counseling
       
8. The individual needs intensive outpatient care because of at least two of the following:
   1. The member’s condition or stage of recovery requires the need for multiple treatment interventions per week in order to stabilize the clinical condition and acquire the necessary skills to be successful in the next level of care.
   2. Marked variability in day-to-day acute capacity to cope with life situations.
   3. A crisis situation is present in family, work and/or interpersonal relationships which may require frequent observation, crisis intervention services, safety planning, problem solving, social services, care coordination, client instruction, support, additional family interventions and other services that may be provided as clinically indicated.

Continued Care Criteria:

Must meet all the following: (criteria #5 should only be used when the member seeks treatment outside of their home geographic area and #6 only if there are multiple recent admissions)

1. A DSM diagnosis is the primary focus of active treatment each program day.
2. There is a reasonable expectation for improvement in the severity of the current condition and behaviors that require a minimum of nine hours each week to provide treatment, structure, and support.
3. The treatment is not primarily social, interpersonal, domiciliary or respite care.
4. Family/support system coordination as evidenced by contact with family to discuss current treatment and support needed to transition and maintain treatment at lower levels of care.
5. If a member is receiving treatment outside of their geographic home, discharge planning proactively reflects and mitigates the higher risk of relapse associated with treatment away from home.
6. If a member has a recent history involving multiple treatment attempts with recidivism, the facility develops and implements a treatment plan focused on increasing motivation, readiness for change, practicing new skills to facilitate the development of recovery and other supports to benefit the member in his/her recovery process.
7. The member is displaying increasing motivation, interest in and ability to actively engage in his/her behavioral health treatment, as evidenced by active participation in groups, cooperation with treatment plan, working on assignments, actively developing discharge plan and other markers of treatment engagement. If the member is not displaying increased motivation, there is evidence of active, timely reevaluation and treatment plan modifications to address the current condition.
8. The member’s treatment plan is centered on the alleviation of disabling symptoms and precipitating psychosocial stressors. There is documentation of member progress towards objective, measurable treatment goals that must be met for the member to transition to the next appropriate level of care. If the member is not progressing appropriately or if the member’s condition has worsened, there is evidence of active, timely reevaluation and treatment plan modifications to address the current needs and stabilize the symptoms necessitating the continued stay.
9. The member continues to need intensive outpatient care because of at least two of the following:
   1. The member’s condition or stage of recovery requires the need for multiple treatment interventions per week in order to stabilize the clinical condition and acquire the necessary skills to be successful in the next level of care.
   2. Marked variability in day-to-day capacity to cope with life situations.
   3. A crisis situation is present in family, work and/or interpersonal relationships which may require resources such as frequent observation, crisis intervention services, safety planning, problem solving, social services, care coordination, client instruction, support, additional family interventions and other services that may be provided as clinically indicated.
10. There is documentation that frequent attempts are made to secure timely access to all current and post-discharge treatment resources and housing (including alternative contingency plans) needed to adequately support timely movement to the next appropriate lower level of care.
11. Despite intensive therapeutic efforts, this level of care is necessary to treat the intensity, frequency and duration of current behaviors and symptoms.

When Psychiatric Intensive Outpatient Programs is not covered

Treatment for Psychiatric Intensive Outpatient Programs is considered not medically necessary when members do NOT meet ALL the criteria listed above in the When Treatment is Covered Section.

Policy Guidelines

Intensive outpatient programs (IOPs) typically provide 3 to 4 hours of psychosocial treatment 1 to 4 days per week (usually 6 to 12 hours of treatment per week), mostly by using a group format, and are appropriate for patients who need a type or frequency of psychosocial treatment that is not currently available in a standard outpatient setting but is available in an IOP.

Symptoms or conditions used to determine the appropriate treatment intensity should be due to the underlying behavioral health diagnosis or represent factors that contribute to destabilization of the underlying diagnosis and are acute in nature or represent a significant worsening over baseline.

Admission to a partial hospital program may be preferable to an intensive outpatient program if daily or near daily management or immediate intervention is necessary. Conditions that may require this intensity of monitoring include medication and comprehensive symptom management; observation and safety planning due to danger to self or others; lack of resiliency and need for repeated reinforcement; extreme mood swings, hopelessness, or isolation with inadequate or unavailable community supports; and substance use monitoring. Immediate intervention may be necessary for crisis situations (e.g., volatile family situations) or when urgent behavioral activation is required (e.g., rapid improvement is necessary to return the individual to vital role functioning)

Impairments in motivation to participate in treatment, limitations to engagement in care, and resistance to change are common in patients with mental health and substance use disorders and may represent a feature of the disease process. A lack of motivation may indicate the need for more intensive services in order to help promote recovery or behavior change. Deficits in motivation or resistance to change should be addressed with therapies designed to enhance motivation to participate in treatment and work toward recovery (e.g., motivational enhancement therapy). The level of motivation and goals/strategies designed to address motivation should be included in the care plan, and a lack of progress toward goals should trigger a reassessment of the care plan (e.g., identification of barriers toward progress, incorporation of new problems that may have developed into the treatment plan, assessment of the appropriateness of initial management strategies), and lead to modification of the plan as appropriate to promote optimal recovery.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: S9480

Only one (1) unit for IOP on a facility or professional claim is allowed per date of service, as these services are defined as per diem and includes all facility, professional, ancillary, and other services rendered to the member at the site.

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

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Medical Director Review 3/2024

Specialty Matched Consultant Advisory Panel Review 6/2024

Medical Director Review 6/2024

Policy Implementation/Update Information

4/1/24 New policy developed. BCBSNC will provide coverage for Psychiatric Intensive Outpatient Programs (IOP) when it is determined to be medically necessary because the medical criteria and guidelines listed within the policy are met. Medical Director review 3/2024. Notification given on 4/1/2024 for effective date 7/1/2024. (tt)

7/17/24 Specialty Matched Consultant Advisory Panel Review 6/2024. References added. Updated coverage criteria to include “treatment days” for clarity. Medical Director review 6/2024. (tt)