LCD for Outpatient Psychiatry and Psychology Services (L26895)


Contractor Information

 
Contractor Name 
National Government Services, Inc.
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


LCD Information

 
LCD ID Number 
L26895 
 
LCD Title 
Outpatient Psychiatry and Psychology Services 
 
Contractor's Determination Number 
L26895 (R7) 
 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  
 
CMS National Coverage Policy 
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(7) of Title XVIII of the Social Security Act excludes routine physical examination.

Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR, Section 410.32 states that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

42 CFR, Section 410.42, describes limitations on coverage of certain services furnished to hospital outpatients.

42 CFR, Section 410.71, describes coverage of clinical psychologist services and supplies incident to a clinical psychologist

42 CFR, Section 410.73 – 410.76, describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.

42 CFR, Section 410.100 – 410.105, describes coverage, exclusions, and requirements for coverage of services furnished to an outpatient at a Comprehensive Outpatient Rehabilitation Facility (CORF).

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6:
    20.4.5 Outpatient Diagnostic Services Under Arrangements
    20.5.1 Coverage of Outpatient Therapeutic Services
    70.1 Outpatient Hospital Psychiatric Services (General)
    70.2 Coverage Criteria for Outpatient Hospital Psychiatric Services
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12:
    40.7 Social and/or Psychological Services
CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1:
    30.1 Biofeedback Therapy
    70.1 Consultations With a Beneficiary’s Family and Associates
    130.1 Inpatient Hospital Stays for the Treatment of Alcoholism
    130.2 Outpatient Hospital Services for Treatment of Alcoholism
    130.3 Chemical Aversion Therapy for Treatment of Alcoholism
    130.4 Electrical Aversion Therapy for Treatment of Alcoholism
    130.5 Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic
    130.6 Treatment of Drug Abuse (Chemical Dependency)
    130.7 Withdrawal Treatments for Narcotic Addictions?
    160.25 Multiple Electroconvulsive Therapy (MECT)
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1:
    50.2.2 Frequency of Billing for Outpatient and Services to FIs
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
    150 Clinical Social Worker (CSW) Services
    160-160.1 Independent Psychologist Services
    170-170.1 Clinical Psychologist Services
 
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
 
Oversight Region
Region I, II, III, V
 
 
Original Determination Effective Date 
For services performed on or after 07/01/2008  
 
Original Determination Ending Date 
 
 
Revision Effective Date 
For services performed on or after 10/01/2010  
 
Revision Ending Date 
 
 
Indications and Limitations of Coverage and/or Medical Necessity 
Abstract:

This LCD outlines the medical necessity requirements for Part A and Part B services in the fields of psychiatry, psychology, clinical social work, and psychiatric nursing for the diagnosis and treatment of various mental disorders and/or diseases.

Indications:

A. Approved Providers of Service
  • Psychiatrists (MD/DO)
  • Clinical psychologists
  • Clinical Social Workers
  • Nurse practitioners
  • Clinical Nurse Specialists
  • Physician Assistants
  • Other providers of mental health services licensed or otherwise authorized by the state in which they practice (e.g., licensed clinical professional counselors, licensed marriage and family therapists). These other providers may not bill Medicare directly for their services, but may provide mental health treatment services to Medicare beneficiaries under the "incident to" provision. For more information see the NGS LCD on Psychological Services Provided "Incident to."
B. General Coverage Requirements:

This section applies to psychiatric services rendered in a hospital outpatient facility, but the medical necessity parameters contained herein may also be applicable to services billed to Part B by individual providers.

Hospital outpatient psychiatric services must be: [1] incident to a physician's service, and [2] reasonable and necessary for the diagnosis or treatment of the patient's condition (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1). This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient's condition. "Incident to" provisions do not apply to professional services performed by nurse practitioners (NPs), clinical nurse specialists (CNSs), clinical psychologists (CPs) or clinical social workers (CSWs). Physician assistants (PAs) are required to perform services under the general supervision of a physician. (See 42 CFR 410.71-76.) Psychiatric services provided incident to a physician's service must be rendered by individuals licensed or otherwise authorized by the State and qualified by their training to perform these services.

Coverage Criteria.The services must meet the following criteria:

Individualized Treatment Plan. Services must be prescribed by a physician and provided under an individualized written plan of treatment established by a physician after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.)
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).

Reasonable Expectation of Improvement. Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).

It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that if treatment services were withdrawn the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).

Some patients may undergo a course of treatment which increases their level of functioning, but then reach a point where further significant increase is not expected (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1). When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary.

Frequency and Duration of Services. There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, and the patient's response. As long as the evidence shows that the patient continues to show improvement in accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms of medical practice, coverage may be continued (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).

When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated and there is no reasonable expectation of improvement, the outpatient psychiatric services are no longer considered reasonable or medically necessary.

Mental Health Services provided in a CORF include:

Social and psychological services include the assessment and treatment of a CORF patient’s mental health and emotional functioning and the response to, and rate of progress of the patient’s rehabilitation plan of treatment including physical therapy services, occupational therapy services, speech-language pathology services and respiratory therapy services.

CORF social and/or psychological covered services are the same, regardless of whether they are provided by a qualified social worker, as defined at 42CFR485.70(l), or a psychologist, as defined at 42CFR485.70(g). Therefore, a CORF may elect to provide these services when they are indicated. Qualifications for individuals providing CORF social and psychological services are, at a minimum, a Bachelors of Science Degree for a social worker and a Masters-level degree for a psychologist.
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 40.7).

Note: Partial Hospitalization is a distinct and organized intensive treatment program for patients who would otherwise require inpatient psychiatric care. Partial Hospitalization services are not addressed in this policy.

C. Outpatient Mental Health Treatment Limitation

Effective January 1, 2010, the current 62.5 percent limitation will be increased as follows:
  1. 2010-2011 = 68.75 percent;
  2. 2012 = 75 percent;
  3. 2013 = 81.25 percent; and,
  4. 2014 and onward = 100 percent.
Effective January 1, 2014, Medicare will pay outpatient mental health services at the same level as other Part B services. That is, at 80 percent of the physician fee schedule.

The outpatient mental health treatment limitation does not apply to psychiatric diagnostic evaluations, diagnostic psychological and neuropsychological testing,or inpatient hospital services.

The limitation applies to procedure codes: 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90846, 90847, 90849, 90853, 90857, 90870, 90880, and 90899, except in in-patient hospital (place of service 21).

When evaluation and management (E&M) codes are reported for treatment of psychiatric illness, except Alzheimer's Disease and related dementias (ICD-9-CM codes 290.0-290.43, 331.0, 331.2), the psychiatric limitation also applies to those services. For patients with Alzheimer's Disease or related dementias, if the primary treatment rendered is psychotherapy, the limitation applies to the therapy services. The limitation does not apply to an E&M service, or a non-psychotherapy service, rendered for the management of Alzheimer's Disease or related dementias.

Effective for claims received on or after 01/01/2010, CPT code 90862 (pharmacologic management) or any successor code is not subject to the limitation.

Code M0064 (brief office visit for the purpose of monitoring or changing drug prescriptions) or any successor code is not subject to the limitation.

D. Specific Coverage Requirements:

Information in this part of the policy has been divided into six (6) sections. These sections address the following CPT/HCPCS procedure codes:
  • General Clinical Psychiatric Diagnostic or Evaluative Interview Procedure (90801)
  • Special Clinical Psychiatric Diagnostic or Evaluative Procedures (90802)
  • Psychiatric Therapeutic Services (90804-90829, 90845, 90847, 90849, 90853, 90857, 90865)
  • Psychiatric Somatotherapy (90862, 90870, M0064)
  • Other Psychiatric Services or Procedures (90875, 90876, 90880, 90882, 90885, 90887, 90889)
  • Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing) (96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120)
Unless otherwise indicated the above codes may be used by psychiatrists or other physicians trained in the treatment of mental illness (MDs/DOs), clinical psychologists, clinical social workers, clinical nurse specialists and other nurses with special training and/or experience in psychiatric nursing beyond the standard curriculum required for a registered nurse (e.g., Masters of Science in psychiatric nursing, or its equivalent [Advanced Registered Nurse Practitioner with a Master's degree in Mental Health, or equivalent to a Master's prepared, certified Clinical Nurse Specialist]).

Psychiatric Diagnostic Interview Examination (90801):

Description: The psychiatric diagnostic interview, codes 90801 is the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient’s ability and capacity to respond to treatment, and an initial plan of treatment. Information may be obtained from not only the patient, but also other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history.

Note: an evaluation and management (E/M) service, (e.g., 99201-99205, 99221-99223, 99241-99255) may be substituted for the initial psychiatric interview provided required elements of the E/M service billed are fulfilled and no psychotherapy was also rendered by the same provider.

Documentation: The medical record must reflect the elements outlined in the above description and must be rendered by a qualified provider (see "Limitations" subsection below).

Comments: This service may be covered once, at the outset of an illness or suspected illness. It may be utilized again for the same patient if a new episode of illness occurs after a hiatus or on admission or readmission to an inpatient status due to complications of the underlying condition. Certain patients, especially children, may require more than one visit for the completion of the initial diagnostic evaluation. The medical record must support the reason for more than one diagnostic interview.

Interactive Psychiatric Diagnostic Interview Examination (90802):

Description: The interactive psychiatric diagnostic interview, code 90802, is used principally to evaluate children and also adults who do not have the ability to interact through ordinary verbal communication. This code may also be applied to the initial evaluation of adult patients with organic mental deficits, or for those who are catatonic or mute.

The Interactive Psychiatric Diagnostic Interview Examination (90802) includes the same components as the Psychiatric Diagnostic Interview Examination that includes history, mental status, disposition, and other components as indicated. However, in the interactive examination, the healthcare provider uses inanimate objects, such as toys and dolls for a child, physical aids and non-verbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or one who does not speak the same language as the healthcare provider.

Documentation: The medical record must reflect the elements outlined in the above description and must be rendered by a qualified provider (see "Limitations" subsection below) and must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels. Additionally, the medical record must include adaptations utilized in the session and the rationale for employing these interactive techniques. If the patient is capable of ordinary verbal communication, this code should not be used. The medical record must include treatment recommendations.

Comments: Procedure code 90802 and all other psychotherapeutic procedure codes (codes 90810-90815, 90823-90829 and 90857) that are interactive techniques are covered for the interactive evaluation/treatment of children who are 16 years of age or younger. Codes 90802, 90810-90815, 90823-90829 and 90857 may also be covered for any psychiatric disorder as specified in the section "ICD-9-CM Codes that Support Medical Necessity" for adults who also have one of the following conditions:
    295.20 Schizophrenic disorders; catatonic type, unspecified
    299.00 Autistic disorder, current or active state
    299.10 Childhood disintegrated disorder, current or active state
    299.80 Other specified pervasive developmental disorder, current or active state
    315.31 Expressive language disorder
    315.35 Childhood onset fluency disorder
    315.39 Developmental speech or language disorder, other
    389.00 Hearing loss; conductive hearing loss; conductive hearing loss, unspecified
    389.01 Conductive hearing loss, external ear
    389.02 Conductive hearing loss, tympanic membrane
    389.03 Conductive hearing loss, middle ear
    389.04 Conductive hearing loss, inner ear
    389.05 Conductive hearing loss, unilateral
    389.06 Conductive hearing loss, bilateral
    389.08 Conductive hearing loss of combined types
    389.10 Sensorineural hearing loss, unspecified
    389.11 Sensory hearing loss, bilateral
    389.12 Neural hearing loss, bilateral
    389.14 Central hearing loss
    389.16 Sensorineural hearing loss, asymmetrical
    389.17 Sensorinueral hearing loss, unilateral
    389.18 Sensorineural hearing loss bilateral
    389.2 Mixed conductive and sensorineural hearing loss
    389.20 Mixed hearing loss, unspecified
    389.21 Mixed hearing loss, unilateral
    389.22 Mixed hearing loss, bilateral
    389.7 Deaf, non-speaking, not elsewhere classifiable
    389.8 Other specified forms of hearing loss
    784.3 Aphasia
    784.41 Aphonia
    784.51 Dysarthria
    784.52 Fluency disorder in conditions classified else where
    784.59 Other speech disturbance
    V65.1 Person consulting on behalf of another person (to be used when an interpreter is required for assessment or therapy)
Psychiatric Therapeutic Procedures (90804-90829, 90845-90849, 90853, 90857, 90865):

Information in this part of the policy has been subdivided into three (3) sections. These sections address the following CPT/HCPCS procedure codes:
  • Codes 90804 – 90829 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy
  • Codes 90845-90857 represent psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy
  • Code 90865 represents narcosynthesis for psychiatric diagnostic and/or therapeutic purposes
A. Codes 90804 – 90829 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy

Description: Procedures 90804 through 90829 (psychotherapy) are defined as "the treatment for mental illness and behavioral disturbances in which the physician or psychiatric health care professional establishes a professional contract with the patient and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development," ( CPT™ Assistant, Summer 1992, page 14) or support current level of functioning. Medical necessity must be supported by the evaluation and a plan with clearly identified goal(s).

Documentation: The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the medical record. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.

Procedure codes 90808, 90809, 90814, 90815, 90821, 90822, 90828, and 90829 (psychotherapy of approximately 75 to 80 minutes) should not be used routinely. These codes should be used for exceptional circumstances. The provider must document in the patient’s medical record the medical necessity of these services and define the exceptional circumstances.

For psychotherapy sessions lasting longer than 90 minutes, reimbursement will only be made if the medical record documents the face-to-face time spent with the patient and the medical necessity for the extended time. Time submitted for the viewing of films or other activities that are not face-to-face psychotherapy are not considered a physician service and are not separately payable.

Comments: While a variety of psychotherapeutic techniques are recognized for coverage under these codes, the services must be performed by persons authorized by their state to render psychotherapy services. Healthcare providers would include: physicians, clinical psychologists, registered nurses with special training (as described in the "Indications" section), and clinical social workers. Medicare coverage of procedure codes 90804-90829 do not include teaching grooming skills, monitoring activities of daily living (ADL), recreational therapy (dance, art, play) or social interaction. Therefore, procedure codes 90804-90829 should not be used to bill for ADL training and/or teaching social interaction skills.

Psychotherapy codes that include and evaluation and management component are payable only to physicians, NPs and CNSs. The evaluation and management component of the services must be documented in the record. A psychotherapy code should not be billed when the service is not primarily a psychotherapy service, that is, when the service could be more accurately described by an evaluation and management or other code.

The duration of a course of psychotherapy must be individualized for each patient. Prolonged treatment may be subject to medical necessity review. The provider must document the medical necessity for prolonged treatment.

B. Codes 90845-90857 represent psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy

Code 90845:

Description: Procedure code 90845 involves the practice of psychoanalysis using special techniques to gain insight into and treat a patient's unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.

Documentation: The medical record must document the indications for psychoanalysis, description of the transference, and the psychoanalytic techniques used.

Comments: The physician or other healthcare professional using this technique must be trained by an accredited program of psychoanalysis. 90845 is not time defined, but the service is usually 45 to 50 minutes and is billed once for each daily session.

Medicare Coverage for Psychoanalytic Services Includes the Following Diagnostic Codes:
    296.20 Major depressive disorder, single episode; unspecified
    296.21 mild
    296.22 moderate
    296.23 severe, without mention of psychotic behavior
    296.24 severe, specified as with psychotic behavior
    296.25 in partial or unspecified remission
    296.30 Major depressive disorder, recurrent episode; unspecified
    296.31 mild
    296.32 moderate
    296.33 severe, without mention of psychotic behavior
    296.34 severe, specified as with psychotic behavior
    296.35 in partial or unspecified remission
    296.36 in full remission
    300.01 Panic disorder without agoraphobia
    300.02 Generalized anxiety disorder
    300.11 Hysteria; Conversion disorders
    300.12 Dissociative amnesia
    300.13 Dissociative fugue
    300.21 Agoraphobia with panic disorder
    300.22 Agoraphobia without mention of panic attacks
    300.23 Social phobia
    300.29 Other isolated or specific phobias
    300.3 Obsessive-compulsive disorders
    300.4 Dysthymic disorder
    309.21 Adjustment reaction; With predominant disturbance of other emotions; Separation anxiety disorder
    V62.84 Suicidal ideation
    V62.85 Homicidal ideation
Codes 90846, 90847, 90849:

Description: Procedure codes 90846, 90847, 90849 describe the treatment of the family unit when maladaptive behaviors of family members are exacerbating the beneficiary's mental illness or interfering with the treatment, or to assist the family in addressing the maladaptive behaviors of the patient and to improve treatment compliance. Code 90846 is used when the patient is not present. Code 90847 is used when the patient is present. Code 90849 is intended for group therapy sessions to support multiple families when similar dynamics are occurring due to common issues confronted in the family members under treatment.

Documentation: The medical record must document the conditions described under the "Description" and "Comments" sections relative to codes 90846, 90847, and 90849.

Comments: The Medicare National Coverage Determinations Manual, Chapter 1, Section 70.1, states that family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient's condition. Examples include:
  • When there is a need to observe and correct, through psychotherapeutic techniques, the patient's interaction with family members (90847).
  • Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient (90846 or 90847).
The term "family" may apply to traditional family members, live-in companions, or significant others involved in the care of the patient. Codes 90846 and 90847 are not timed but are typically 45 to 60 minutes in duration.

Codes 90846 and 90847 do not pertain to consultation and interaction with paid staff members at an institution. Facility staff members are not considered "significant others" for the purposes of this LCD.

Code 90849 represents multiple-family group psychotherapy and is generally non-covered by Medicare. Such group therapy is usually directed to the effects of the patient's condition on the family and its purpose is to support the affected family members. Therefore, code 90849 does not meet Medicare's standards of being a therapy primarily directed toward treating the beneficiary's condition. Claims for 90849 may be approved on an individual consideration basis.

Codes 90853 and 90857:

Description: Codes 90853 and 90857* represent psychotherapy administered in a group setting, involving no more than 12 participants, facilitated by a trained therapist simultaneously providing therapy to these multiple patients. The group therapy session typically lasts 45 to 60 minutes. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support.

Documentation: The record must indicate that the guidelines under the "Description" and "Comments" sections were followed.

Comments: Group therapy, since it involves psychotherapy, must be led by a person who is licensed or otherwise authorized by the state in which he or she practices to perform this service. This will usually mean a psychiatrist, psychologist, clinical social worker, clinical nurse specialist, or other person authorized by the state to perform this service. Registered nurses with special training, as described in the "Indications and Limitations of Coverage and/or Medical Necessity" section, may also be considered eligible for coverage. For Medicare coverage, group therapy does not include: socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, or motion therapy, etc.

*See below for additional information on code 90857.

Codes 90810-90815, 90823-90829 and 90857:

As a reminder, codes 90810-90815, 90823-90829 and 90857 are used when the patient or patients in the group setting do not have the ability to interact by ordinary verbal communication and therefore, non-verbal communication skills are employed or an interpreter may be necessary. The guidelines in "Description," "Documentation," and "Comments," sections for CPT code 90802 apply to CPT codes 90810-90815, 90823-90829 and 90857.

C. Code 90865 represents narcosynthesis for psychiatric diagnostic and/or therapeutic purposes

Description: Procedure code 90865 is used for the administration of sedative or tranquilizer drugs, usually intravenously, to relax the patient and remove inhibitions for discussion of subjects difficult for the patient to discuss freely in the fully conscious state.

Documentation: The medical record should document the medical necessity of this procedure (e.g., the patient had difficulty verbalizing their psychiatric problems without the aid of the drug). The record should also document the specific pharmacological agent, dosage administered, and whether the technique was effective or non-effective.

Comments: Use of CPT code 90865 is restricted to physicians (MD/DO) only.

Section IV: Psychiatric Somatotherapy (90862, 90870, M0064)

These codes describe pharmacologic/medication management and/or electroconvulsive therapy.

Code 90862:

Description: Code 90862 is intended for use by the physician (or masters prepared psychiatric nurse with state authorized prescribing privileges) who is prescribing pharmacological therapy for a patient with any psychiatric disorder. Relevant interval history is obtained, a focused mental status examination is performed, and medical decision making (i.e., assessment of treatment response and ongoing treatment formulation) occurs during such a visit and documented. Psychopharmacologic agents may be initiated or adjusted. It may be used for the patient whose psychotherapy is being rendered by another health professional and the billing physician is treating with psychotropic medication. The services include 1) prescribing medication, 2) monitoring the effect of medication and its side effects, 3) adjusting the dosage (the medical record must include this information in addition to the diagnosis/diagnoses treated), and 4) psychotherapy. Any psychotherapy provided is minimal and is usually supportive in nature.

Documentation: The record must document that the guidelines under the "Description" and "Comments" sections are followed.

Comments: The physician work Relative Value Units (RVUs) for this code indicate this code represents a 15-20 minute service. For brief encounters for prescription renewal, use a low level E/M code or M0064. See Supplemental Instructions Article for additional information.

Code M0064:

HCPCS code M0064 is intended to refer to a patient encounter by the physician, physician assistant, or advanced registered nurse with psychiatric training and acting within the scope of practice as previously described, to renew and/or adjust a prescription for a patient who is essentially clinically stable. Documentation should include a brief interval history and pertinent elements of the mental status examination to summarize the patient's clinical condition. Based on the assignment of relative value units (RVUs), the work involved in M0064 is similar to code 99212. Time spent is generally up to ten minutes.

Code 90870:

Description: Code 90870, electroconvulsive therapy (ECT), is described as the application of electric current to the brain, through scalp electrodes to produce a seizure. It is used primarily to treat major depressive disorder when antidepressant medication is contraindicated and for certain other clinical conditions.

Comments: When a psychiatrist performs both the ECT and the associated anesthesia, no separate payment is made for the anesthesia. Code 90870 is limited to use by physicians (MD/DO) only.

Section V: Other Psychiatric Services (90875, 90876, 90880, 90882, 90885, 90887, 90889) [CPT codes 90875, 90876 and 90882 are not covered by Medicare]:

A. Description: Codes 90875 and 90876 are described as individual psychophysiological therapy incorporating biofeedback training by any modality (face to face with patient), with psychotherapy (e.g., insight-oriented, behavior-modifying or supportive psychotherapy).

Comments: The Medicare National Coverage Determinations Manual, Chapter 1, Section 30.1, restricts the use of biofeedback. Medicare does not cover biofeedback for the treatment of psychosomatic disorders.

B. Description: Code 90880 is described as hypnotherapy. Hypnosis is an artificially induced alteration of consciousness in which the patient is in a state of increased suggestibility.

Documentation: Claims must be submitted with a covered diagnosis.

Comments: Hypnosis may be used for diagnostic or therapeutic purposes. Medicare will cover hypnotherapy for the following diagnoses:
    300.11 Conversion disorder
    300.12 Dissociative amnesia
    300.13 Dissociative fugue
    300.14 Dissociative identity disorder
    300.15 Dissociative disorder or reaction, unspecified
    300.21 Agoraphobia with panic disorder
    300.22 Agoraphobia without mention of panic attacks
    300.23 Social phobia
    300.29 Other isolated or specific phobias
    307.80 Psychogenic pain, site unspecified
    308.3 Other acute reaction to stress
    308.4 Mixed disorders as reaction to stress
    308.9 Unspecified acute reaction to stress
    309.0 Brief depressive reaction
    309.1 Prolonged depressive reaction
    309.21 Separation anxiety disorder
    309.24 Adjustment disorder with anxiety
    309.28 Adjustment disorder with mixed anxiety and depressed mood
    309.3 Adjustment disorder with disturbance of conduct
    309.4 Adjustment disorder with mixed disturbance of emotions and conduct
    309.81 Posttraumatic stress disorder
Note: CPT code 90882 (environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions) is not covered by Medicare.

C. Description: Code 90885 is used when a physician or advanced mental health practitioner is asked to do a review of records for psychiatric evaluation without direct patient contact. This may be accomplished at the request of an agency or peer review organization. It may also be employed as part of an overall evaluation of a patient's psychiatric illness or suspected psychiatric illness, to aid in the diagnosis and/or treatment plan.

D. Description: Code 90887 is used when the treatment of the patient may require explanations to the family, employers, or other involved persons for their support in the therapy process. This may include reporting of examinations, procedures, and other accumulated data.

E. Description: Code 90889 involves preparation of reports for insurance companies, agencies, courts, etc.

Comments: Codes 90885, 90887, and 90889 represent administrative services that do not involve face to face contact with the patient and are not covered by Medicare.

F. Description: Code 90899 is defined as "unlisted psychiatric service or procedure" and should not be used if the service is described by one of the above specified codes. Psychiatric procedures billed using code 90899 may be covered on an individual consideration basis.

Section VI: Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing) (96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, and 96120):

A. Description: Codes 96101, 96102, and 96103 (psychological testing) include the administration, interpretation, and scoring of the tests mentioned in the CPT descriptions and other medically accepted tests for evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing treatment and prognosis.

Documentation: The medical record must indicate the presence of mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.

Comments: These codes do not represent psychotherapeutic modalities, but are diagnostic aids. Use of such tests when mental illness is not suspected would be a screening procedure not covered by Medicare. Each test performed must be medically necessary. Therefore, standardized batteries of tests are not acceptable unless each test in the battery is medically necessary.

Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing.

B. Description: Codes 96105, 96110, 96111, 96116, 96118, 96119, and 96120 are defined by their CPT narratives. Code 96105 represents the formal evaluation of aphasia using a psychometric instrument such as the Boston Diagnostic Aphasia Examination. This testing is typically performed once during treatment and the medical necessity for such testing should be documented. Repeat testing should only be done if there is a significant change in the patient’s aphasic condition.

Codes 96118, 96119, and 96120 describe testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. Examples of problems that might lead to neuropsychological testing are:
  • Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia)
  • Differential diagnosis between psychogenic and neurogenic syndromes
  • Delineation of the neurocognitive effects of central nervous system disorders
  • Neurocognitive monitoring of recovery or progression of central nervous system disorders; or
  • Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders.
Documentation: The medical record must document that the guidelines outlined in the "Description" and "Comments" sections were followed.

Comments: The content of neuropsychological testing procedures (96118, 96119, 96120) differs from that of psychological testing (96101-96111) in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample cognitive and performance domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.). These procedures are objective and quantitative in nature and require the patient to directly demonstrate his/her level of competence in a particular cognitive domain. Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT).

Typically, psychological testing will require from four (4) to six (6) hours to perform, including administration, scoring and interpretation. If the testing is done over several days, the testing time should be combined and reported all on the last date of service. If the testing time exceeds eight (8) hours, a report may be requested to indicate the medical necessity for extended testing.

Limitations:

Severe and profound mental retardation (ICD-9 codes 318.1, 318.2, 319,) is never covered for psychotherapy services (CPT codes 90804-90829). In such cases, rehabilitative, evaluation and management (E/M) codes, or pharmacological management codes should be reported.

Patients with dementia represent a very vulnerable population in which co-morbid psychiatric conditions are common. However, for such a patient to benefit from psychotherapy services requires that their dementia to be mild and that they retain the capacity to recall the therapeutic encounter from one session, individual or group, to another. This capacity to meaningfully benefit from psychotherapy must be documented in the medical record. Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective.

Any diagnostic or psychotherapeutic procedure rendered by a practitioner not practicing within the scope of his/her licensure or other State authorization will be denied.

Psychiatric services billed under the hospital outpatient benefit must be provided in distinct outpatient settings. Outpatient hospital services provided in conjunction with inpatient services, or under the auspices of an excluded inpatient unit, residential treatment center, residential facility, or skilled nursing facility, are not in compliance with Medicare regulations and payment will be denied. Payment may be made for psychiatric services in these settings by individual providers billing Part B.

The following services do not represent reasonable and necessary outpatient psychiatric services and/or coverage is excluded under section 1862(a)(1)(A) of the Social Security Act:
  • day care programs, which provide primarily social, recreational, or diversional activities, custodial or respite care;
  • programs attempting to enhance emotional wellness, e.g., day care programs;
  • services to a skilled nursing facility resident that should be expected to be provided by the nursing facility staff;
  • vocational training when services are related solely to specific employment opportunities, work skills, or work settings;
  • biofeedback training for psychosomatic conditions;
  • recovery meetings such as Alcoholics Anonymous, 12 Step, Al Anon, Narcotics Anonymous, due to their free availability in the community;
  • telephone calls to patients, collateral resources and agencies;
  • evaluation of records, reports, tests, and other data;
  • explanation of results to family, employers, or others;
  • preparation of reports for agencies, courts, schools, or insurance companies, etc. for medicolegal or informational purposes;
  • screening procedures provided routinely to patients without regard to the signs and symptoms of the patient’s mental illness.
The following services are excluded from the scope of outpatient hospital psychiatric services defined in Section 1927(k) of the Social Security Act:
  • services to hospital inpatients;
  • meals, transportation;
  • supervision or administration of self-administered medications and supplying medications for home use.
Evaluations of the mental status that can be performed within the clinical interview, such as a list of questions concerning symptoms of depression or organic brain syndrome, corresponding to brief questionnaires such as the Folstein Mini Mental Status Examination or the Beck Depression Scale, should not be billed as psychological testing (96101-96120), but is considered included in the clinical interview.

Psychological testing to evaluate adjustment reactions or dysphoria associated with placement in a nursing home is not medically necessary. Routine testing of nursing home patients is considered screening and is not covered.

Each psychological test administered must be individually medically necessary. A standard battery of tests is only medically necessary if each individual test in the battery is medically necessary.

The psychological testing codes should not be reported by the treating physician for reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services.

Payment for psychological testing is limited to physicians, clinical psychologists, and on a limited basis, to qualified non-physician practitioners (e.g., speech language pathologists for aphasia evaluation).

Other Comments:

For claims submitted to the fiscal intermediary or Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.

Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

General Comments Regarding Coverage of Outpatient Hospital Diagnostic and Therapeutic Services:

Therapeutic services defined as hospital services and provided by a hospital on an outpatient basis are incident to the services of physicians in the treatment of patients. To be covered as incident to physicians' services, the services and supplies must be furnished by the hospital or CAH or under arrangement made by the hospital or CAH (see section 20.1.1 of this chapter). The services and supplies must be furnished as an integral, although incidental, part of the physician's professional services in the course or treatment of an illness or injury (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.5.1).

The services and supplies must be furnished under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law, furnished by hospital personnel and under the direct supervision of a physician or clinical psychologist as defined in 42 CFR 410.32(b)(3)(ii) and 482.12. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.5.1).

When the hospital makes arrangements with others for diagnostic services, such services are covered under Part B as diagnostic tests whether furnished in the hospital or in other facilities. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.4.5). 
 


Coding Information

 
Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital
 
 
Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

Use of revenue code 0910 to report certain psychiatric/psychological treatment and services was discontinued by the National Uniform Billing Committee on 10/15/03. Revenue code 0900 will now be used in place of revenue code 0910 effective for claims with dates of service on or after October 16, 2003 (CMS Publication 100-20, Medicare One-Time Notification Manual, Transmittal No. 98, Change Request #3343, July 23, 2004).

Providers submitting claims with bill type 12X are to report revenue code 0918 (psychiatric / psychological testing).

0900 Behavioral Health Treatment/Services - General Classification
0901 Behavioral Health Treatment/Services - Electroshock Treatment
0914 Behavioral Health Treatment/Services - Individual Therapy
0915 Behavioral Health Treatment/Services - Group Therapy
0916 Behavioral Health Treatment/Services - Family Therapy
0918 Behavioral Health Treatment/Services - Testing
 
 
CPT/HCPCS Codes 

90801 Psy dx interview
90802 Intac psy dx interview
90804 Psytx, office, 20-30 min
90805 Psytx, off, 20-30 min w/e&m
90806 Psytx, off, 45-50 min
90807 Psytx, off, 45-50 min w/e&m
90808 Psytx, office, 75-80 min
90809 Psytx, off, 75-80, w/e&m
90810 Intac psytx, off, 20-30 min
90811 Intac psytx, 20-30, w/e&m
90812 Intac psytx, off, 45-50 min
90813 Intac psytx, 45-50 min w/e&m
90814 Intac psytx, off, 75-80 min
90815 Intac psytx, 75-80 w/e&m
90816 Psytx, hosp, 20-30 min
90817 Psytx, hosp, 20-30 min w/e&m
90818 Psytx, hosp, 45-50 min
90819 Psytx, hosp, 45-50 min w/e&m
90821 Psytx, hosp, 75-80 min
90822 Psytx, hosp, 75-80 min w/e&m
90823 Intac psytx, hosp, 20-30 min
90824 Intac psytx, hsp 20-30 w/e&m
90826 Intac psytx, hosp, 45-50 min
90827 Intac psytx, hsp 45-50 w/e&m
90828 Intac psytx, hosp, 75-80 min
90829 Intac psytx, hsp 75-80 w/e&m
90845 Psychoanalysis
90846 Family psytx w/o patient
90847 Family psytx w/patient
90849 Multiple family group psytx
90853 Group psychotherapy
90857 Intac group psytx
90862 Medication management
90865 Narcosynthesis
90870 Electroconvulsive therapy
90880 Hypnotherapy
90885 Psy evaluation of records
90887 Consultation with family
90889 Preparation of report
90899 Psychiatric service/therapy
96101 Psycho testing by psych/phys
96102 Psycho testing by technician
96103 Psycho testing admin by comp
96105 Assessment of aphasia
96110 Developmental test, lim
96111 Developmental test, extend
96116 Neurobehavioral status exam
96118 Neuropsych tst by psych/phys
96119 Neuropsych testing by tec
96120 Neuropsych tst admin w/comp
M0064 Visit for drug monitoring
 
 
ICD-9 Codes that Support Medical Necessity 
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Note: Every effort has been made to attempt to reflect the psychiatric diagnostic coding conventions of DSM-IV-TR™ in the psychiatric diagnoses section. Cases that fall outside DSM-IV-TR™ coding may be considered for coverage on a case-by-case basis.

Psychiatric Diagnoses:

290.40 VASCULAR DEMENTIA, UNCOMPLICATED
290.41 VASCULAR DEMENTIA, WITH DELIRIUM
290.42 VASCULAR DEMENTIA, WITH DELUSIONS
290.43 VASCULAR DEMENTIA, WITH DEPRESSED MOOD
291.0 ALCOHOL WITHDRAWAL DELIRIUM
291.1 ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER
291.3 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS
291.5 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS
291.81 ALCOHOL WITHDRAWAL
291.89 OTHER SPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS
291.9 UNSPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS
292.0 DRUG WITHDRAWAL
292.11 DRUG-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS
292.12 DRUG-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS
292.81 DRUG-INDUCED DELIRIUM
292.82 DRUG-INDUCED PERSISTING DEMENTIA
292.83 DRUG-INDUCED PERSISTING AMNESTIC DISORDER
292.84 DRUG-INDUCED MOOD DISORDER
292.89 OTHER SPECIFIED DRUG-INDUCED MENTAL DISORDERS
292.9 UNSPECIFIED DRUG-INDUCED MENTAL DISORDER
293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE
293.81 PSYCHOTIC DISORDER WITH DELUSIONS IN CONDITIONS CLASSIFIED ELSEWHERE
293.82 PSYCHOTIC DISORDER WITH HALLUCINATIONS IN CONDITIONS CLASSIFIED ELSEWHERE
293.83 MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
293.84 ANXIETY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
293.89 OTHER SPECIFIED TRANSIENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE, OTHER
293.9 UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
294.0 AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
294.10 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE
294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE
294.8 OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
294.9 UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
295.10 DISORGANIZED TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.20 CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.30 PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.40 SCHIZOPHRENIFORM DISORDER, UNSPECIFIED
295.60 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, UNSPECIFIED
295.70 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED
295.90 UNSPECIFIED TYPE SCHIZOPHRENIA UNSPECIFIED STATE
296.00 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED
296.01 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD
296.02 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE
296.03 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.04 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.05 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION
296.06 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION
296.20 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE
296.21 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MILD DEGREE
296.22 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE DEGREE
296.23 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.24 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.25 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.26 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN FULL REMISSION
296.30 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE
296.31 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE
296.32 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE
296.33 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.34 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.35 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.36 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION
296.40 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, UNSPECIFIED
296.41 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD
296.42 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MODERATE
296.43 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.44 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.45 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN PARTIAL OR UNSPECIFIED REMISSION
296.46 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN FULL REMISSION
296.50 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED
296.51 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD
296.52 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE
296.53 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.54 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.55 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR UNSPECIFIED REMISSION
296.56 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION
296.60 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED
296.61 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD
296.62 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE
296.63 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.64 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.65 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION
296.66 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION
296.7 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED
296.80 BIPOLAR DISORDER, UNSPECIFIED
296.89 OTHER AND UNSPECIFIED BIPOLAR DISORDERS, OTHER
296.90 UNSPECIFIED EPISODIC MOOD DISORDER
297.1 DELUSIONAL DISORDER
297.3 SHARED PSYCHOTIC DISORDER
298.8 OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS
298.9 UNSPECIFIED PSYCHOSIS
299.00 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
299.10 CHILDHOOD DISINTEGRATIVE DISORDER, CURRENT OR ACTIVE STATE
299.80 OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, CURRENT OR ACTIVE STATE
300.00 ANXIETY STATE UNSPECIFIED
300.01 PANIC DISORDER WITHOUT AGORAPHOBIA
300.02 GENERALIZED ANXIETY DISORDER
300.11 CONVERSION DISORDER
300.12 DISSOCIATIVE AMNESIA
300.13 DISSOCIATIVE FUGUE
300.14 DISSOCIATIVE IDENTITY DISORDER
300.15 DISSOCIATIVE DISORDER OR REACTION UNSPECIFIED
300.16 FACTITIOUS DISORDER WITH PREDOMINANTLY PSYCHOLOGICAL SIGNS AND SYMPTOMS
300.19 OTHER AND UNSPECIFIED FACTITIOUS ILLNESS
300.21 AGORAPHOBIA WITH PANIC DISORDER
300.22 AGORAPHOBIA WITHOUT PANIC ATTACKS
300.23 SOCIAL PHOBIA
300.29 OTHER ISOLATED OR SPECIFIC PHOBIAS
300.3 OBSESSIVE-COMPULSIVE DISORDERS
300.4 DYSTHYMIC DISORDER
300.6 DEPERSONALIZATION DISORDER
300.7 HYPOCHONDRIASIS
300.81 SOMATIZATION DISORDER
300.82 UNDIFFERENTIATED SOMATOFORM DISORDER
301.13 CYCLOTHYMIC DISORDER
301.20 SCHIZOID PERSONALITY DISORDER UNSPECIFIED
301.22 SCHIZOTYPAL PERSONALITY DISORDER
301.4 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
301.6 DEPENDENT PERSONALITY DISORDER
301.7 ANTISOCIAL PERSONALITY DISORDER
301.81 NARCISSISTIC PERSONALITY DISORDER
301.82 AVOIDANT PERSONALITY DISORDER
301.83 BORDERLINE PERSONALITY DISORDER
302.2 PEDOPHILIA
302.3 TRANSVESTIC FETISHISM
302.4 EXHIBITIONISM
302.6 GENDER IDENTITY DISORDER IN CHILDREN
302.70 PSYCHOSEXUAL DYSFUNCTION UNSPECIFIED
302.71 HYPOACTIVE SEXUAL DESIRE DISORDER
302.72 PSYCHOSEXUAL DYSFUNCTION WITH INHIBITED SEXUAL EXCITEMENT
302.73 FEMALE ORGASMIC DISORDER
302.74 MALE ORGASMIC DISORDER
302.75 PREMATURE EJACULATION
302.76 DYSPAREUNIA, PSYCHOGENIC
302.79 PSYCHOSEXUAL DYSFUNCTION WITH OTHER SPECIFIED PSYCHOSEXUAL DYSFUNCTIONS
303.90 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED DRINKING BEHAVIOR
304.00 OPIOID TYPE DEPENDENCE UNSPECIFIED USE
304.10 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, UNSPECIFIED
304.20 COCAINE DEPENDENCE UNSPECIFIED USE
304.30 CANNABIS DEPENDENCE UNSPECIFIED USE
304.40 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE UNSPECIFIED USE
304.50 HALLUCINOGEN DEPENDENCE UNSPECIFIED USE
304.60 OTHER SPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
304.70 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE UNSPECIFIED USE
304.80 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG UNSPECIFIED USE
305.00 NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR
305.20 NONDEPENDENT CANNABIS ABUSE UNSPECIFIED USE
305.30 NONDEPENDENT HALLUCINOGEN ABUSE UNSPECIFIED USE
305.40 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED
305.50 NONDEPENDENT OPIOID ABUSE UNSPECIFIED USE
305.60 NONDEPENDENT COCAINE ABUSE UNSPECIFIED USE
305.70 NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE UNSPECIFIED USE
305.90 OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED USE
306.51 PSYCHOGENIC VAGINISMUS
307.1 ANOREXIA NERVOSA
307.20 TIC DISORDER UNSPECIFIED
307.21 TRANSIENT TIC DISORDER
307.22 CHRONIC MOTOR OR VOCAL TIC DISORDER
307.23 TOURETTE’S DISORDER
307.3 STEREOTYPIC MOVEMENT DISORDER
307.42 PERSISTENT DISORDER OF INITIATING OR MAINTAINING SLEEP
307.44 PERSISTENT DISORDER OF INITIATING OR MAINTAINING WAKEFULNESS
307.45 CIRCADIAN RHYTHM SLEEP DISORDER OF NONORGANIC ORIGIN
307.46 SLEEP AROUSAL DISORDER
307.50 EATING DISORDER UNSPECIFIED
307.51 BULIMIA NERVOSA
307.52 PICA
307.53 RUMINATION DISORDER
307.59 OTHER DISORDERS OF EATING
307.6 ENURESIS
307.7 ENCOPRESIS
307.80 PSYCHOGENIC PAIN SITE UNSPECIFIED
307.89 OTHER, PAIN DISORDER RELATED TO PSYCHOLOGICAL FACTORS
308.3 OTHER ACUTE REACTIONS TO STRESS
308.9 UNSPECIFIED ACUTE REACTION TO STRESS
309.0 ADJUSTMENT DISORDER WITH DEPRESSED MOOD
309.21 SEPARATION ANXIETY DISORDER
309.22 EMANCIPATION DISORDER OF ADOLESCENCE AND EARLY ADULT LIFE
309.24 ADJUSTMENT DISORDER WITH ANXIETY
309.28 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD
309.3 ADJUSTMENT DISORDER WITH DISTURBANCE OF CONDUCT
309.4 ADJUSTMENT DISORDER WITH MIXED DISBURBANCE OF EMOTIONS AND CONDUCT
309.81 POSTTRAUMATIC STRESS DISORDER
310.1 PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE
311 DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED
312.30 IMPULSE CONTROL DISORDER UNSPECIFIED
312.31 PATHOLOGICAL GAMBLING
312.32 KLEPTOMANIA
312.33 PYROMANIA
312.34 INTERMITTENT EXPLOSIVE DISORDER
312.35 ISOLATED EXPLOSIVE DISORDER
312.81 CONDUCT DISORDER CHILDHOOD ONSET TYPE
312.82 CONDUCT DISORDER ADOLESCENT ONSET TYPE
312.89 OTHER SPECIFIED CONDUCT DISORDER NOT ELSEWHERE CLASSIFIED
313.23 SELECTIVE MUTISM
313.81 OPPOSITIONAL DEFIANT DISORDER
313.82 IDENTITY DISORDER OF CHILDHOOD OR ADOLESCENCE
313.89 OTHER EMOTIONAL DISTURBANCES OF CHILDHOOD OR ADOLESCENCE
314.00 ATTENTION DEFICIT DISORDER OF CHILDHOOD WITHOUT HYPERACTIVITY
314.01 ATTENTION DEFICIT DISORDER OF CHILDHOOD WITH HYPERACTIVITY
314.9 UNSPECIFIED HYPERKINETIC SYNDROME OF CHILDHOOD
315.00 DEVELOPMENTAL READING DISORDER UNSPECIFIED
315.1 MATHEMATICS DISORDER
315.2 OTHER SPECIFIC DEVELOPMENTAL LEARNING DIFFICULTIES
315.31 EXPRESSIVE LANGUAGE DISORDER
315.32 MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER
315.35 CHILDHOOD ONSET FLUENCY DISORDER
315.39 OTHER DEVELOPMENTAL SPEECH DISORDER
315.4 DEVELOPMENTAL COORDINATION DISORDER
315.9 UNSPECIFIED DELAY IN DEVELOPMENT
316 PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE
317 MILD MENTAL RETARDATION
318.0 MODERATE MENTAL RETARDATION
318.1 SEVERE MENTAL RETARDATION
318.2 PROFOUND MENTAL RETARDATION
327.02 INSOMNIA DUE TO MENTAL DISORDER
327.15 HYPERSOMNIA DUE TO MENTAL DISORDER
327.41 CONFUSIONAL AROUSALS
332.1 SECONDARY PARKINSONISM
333.72 ACUTE DYSTONIA DUE TO DRUGS
333.82 OROFACIAL DYSKINESIA
333.90 UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER
333.92 NEUROLEPTIC MALIGNANT SYNDROME
333.99 OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS
347.00 NARCOLEPSY, WITHOUT CATAPLEXY
347.01 NARCOLEPSY, WITH CATAPLEXY
347.10 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITHOUT CATAPLEXY
347.11 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITH CATAPLEXY
780.09 ALTERATION OF CONSCIOUSNESS OTHER
780.52 INSOMNIA, UNSPECIFIED
995.52 CHILD NEGLECT (NUTRITIONAL)
995.53 CHILD SEXUAL ABUSE
995.54 CHILD PHYSICAL ABUSE
995.81 ADULT PHYSICAL ABUSE
995.83 ADULT SEXUAL ABUSE
V62.84 SUICIDAL IDEATION
V62.85 HOMICIDAL IDEATION
Other Medical Diagnoses Not Included in DSM-IV™:


090.40 JUVENILE NEUROSYPHILIS UNSPECIFIED
090.41 CONGENITAL SYPHILITIC ENCEPHALITIS
290.10 PRESENILE DEMENTIA UNCOMPLICATED
290.11 PRESENILE DEMENTIA WITH DELIRIUM
290.12 PRESENILE DEMENTIA WITH DELUSIONAL FEATURES
290.13 PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES
290.20 SENILE DEMENTIA WITH DELUSIONAL FEATURES
290.21 SENILE DEMENTIA WITH DEPRESSIVE FEATURES
290.3 SENILE DEMENTIA WITH DELIRIUM
310.0 FRONTAL LOBE SYNDROME
310.2 POSTCONCUSSION SYNDROME
310.8 OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE
310.9 UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE
315.01 ALEXIA
315.02 DEVELOPMENTAL DYSLEXIA
315.09 OTHER SPECIFIC DEVELOPMENTAL READING DISORDER
331.0 ALZHEIMER'S DISEASE
331.11 PICK'S DISEASE
331.19 OTHER FRONTOTEMPORAL DEMENTIA
331.82 DEMENTIA WITH LEWY BODIES
780.93 MEMORY LOSS
780.97 ALTERED MENTAL STATUS
784.3 APHASIA
784.41 APHONIA
784.51 DYSARTHRIA
784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
784.59 OTHER SPEECH DISTURBANCE
 
 
Diagnoses that Support Medical Necessity 
Not applicable 
 
ICD-9 Codes that DO NOT Support Medical Necessity 
Not applicable
 
 
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 
 
 
Diagnoses that DO NOT Support Medical Necessity 
Not applicable 


General Information

 
Documentation Requirements 
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has imposed specific restrictions on access to psychotherapy notes. These restrictions are outlined in the Code of Federal Regulations (CFR), 45 CFR, parts 160 and 164 (The Privacy Rule). Providers are exempt from submitting psychotherapy notes without patient authorization when the notes in question fit the Privacy Rule definition in 45 CFR Section 164.501. This section defines psychotherapy notes as "notes recorded by a mental health professional (in any medium) which document or analyze the contents of a counseling session and that are separated from the rest of a medical record."

45 CFR § 164.501 states that "the provider is responsible for extracting information required to perform a review for medical necessity." The provider, therefore, is expected to document information potentially necessary for review in a manner that will allow submission if this information without release of psychotherapy details that are protected by the Privacy Rule.

This following information is excluded from the protected information in 45 CFR §164.501, and must be included in all psychiatric medical record documentation and made available upon request:

- Name of beneficiary and date of service
- Type of service (individual, group, family, interactive, etc.)
- Time element, where duration of the face-to-face contact is the determining factor for coding the service rendered
- Modalities and frequency of treatment furnished
- A clinical note for each encounter, where in the aggregate, summarizes the following items: diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis, and progress to date. Elements such as treatment plans, functional status and prognostic assessment are expected to be documented, updated and available for review, but do not need to be delineated for each individual date of service.
- Identity and professional credentials of the person performing service

For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these non-verbal interactive techniques

For psychotherapy services that include a medical evaluation and management component, documentation of the medical evaluation or management component of the treatment, including prescriptions, monitoring of medication effects, co-morbid medical conditions evaluated, and results of clinical tests.

Group therapy session notes must be prepared within a reasonable time period after the rendering of professional services consistent with accepted practice, and can be organized according to the general session note guidelines for individual therapy or the clinician may elect to use the following group note format:

• One portion of the note that is common to all patients, documenting date, length of time for the session, along with key issues presented. Names of the patients in the group should not appear in this group note.

• A second portion of the note, for each patient's record, commenting on that particular patient's participation in the group process and any significant changes in patient status. As outlined in HIPAA regulations referenced above, the note should exclude sensitive content of the patients' conversation.

While there are no specific limitations on the frequency or length of time that outpatient psychiatric services may be covered, there are many factors, including the nature of the illness, prior history, goals of treatment, and the patient’s response, that affect the outcome of treatment. When outpatient psychiatric services are provided at a high frequency or long duration, the plan of treatment, progress notes, and condition of the patient should justify the intensity of the services rendered.

For psychotherapy services, there should be documentation of the patient's capacity to participate in and benefit from psychotherapy, especially if the patient is in any way cognitively impaired. The medical record should document the target symptoms, goals of therapy and methods of monitoring outcome. There should be documentation in the medical record of how the treatment is expected to improve the health status or function of the patient.

Those hospitals that provide services at off-campus locations must clearly document in the medical record the location of the billed services, and that the services were properly supervised. 
 
Appendices 
Not applicable 
 
Utilization Guidelines 
Not applicable 
 
Sources of Information and Basis for Decision 
This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

  1. Academy of Psychosomatic Medicine. Practice Guideline for Psychiatric Consultation in the General Medical Setting. Psychosomat 1998; 39(4):S8-30.

  2. American Academy of Child & Adolescent Psychiatry. Practice Parameters for the Psychiatric Assessment of Children and Adolescents. J Am Acad Child Adolesc Psychiatry. 1997;36(10S):4S-20S.

  3. American Medical Association. CPT Assistant. Summer 1992, page 14.

  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – Text Revision (DSM-IV-TR). American Psychiatric Association. Washington, D.C., 2000.

  5. American Psychiatric Association. Practice Guideline for Major Depressive Disorder in Adults. Retrieved August 24, 1999 from the World Wide Web: http://www.psych.org/clin_res/pg_major.html

  6. American Psychiatric Association. Practice Guideline for Psychiatric Evaluation of Adults. Retrieved August 24, 1999 from the World Wide Web: http://www.psych.org/clin_res/pg_adult.html

  7. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia. Retrieved August 24, 1999 from the World Wide Web: http://www.psych.org/clin_res/pg_schizo.html

  8. American Psychiatric Press. Psychotherapy for Personality Disorders. Edited by John G. Gunderson, MD and Glen O. Gabbard, MD. American Psychiatric Press, Inc. 1999

  9. Carrier Medical Directors Psychology/Psychiatry Clinical Workgroup model policy, April 18,1996; revised February 5, 1998.

  10. CPT Assistant. Summer, 1992, pages 12-16 American Medical Association

  11. DSM IV, 1997. Mood Disorder, 317-391. American Psychiatric Association

  12. Empire Medicare Services (New Jersey), policy #V-38A – Psychiatric Pharmacotherapy, www.empiremedicare.com

  13. Empire Medicare Services, policy Ymed #12, pub. May, 1998, Medicare News Brief 98-5. (www.empiremedicare.com)

  14. Kaplan, Harold I, Benjamin T. Sadock and Jack A. Grebb, eds.1994. Kaplan and Sadock's Synopsis of Psychiatry. 221-236, 824-864. Williams & Wilkens

  15. Levenson, Hanna, Ph.D. and Stephen Butler, Ph.D. "Brief Dynamic Individual Psychotherapy". 1133-1155. Robert Hales, Stuart C. Yodofsky and John A. Talbert, eds. 1999. Textbook of Psychiatry. American Psychiatric Press

  16. Noridian Med B Newsletter: issue 178, Dec., 1999, pp. "Psychiatric Guidelines"

  17. Psychiatric Clinics of North America, 23(1), Borderline Personality Disorder. W.B.Saunders, New York, NY, 2000. 170-185.

  18. Psychodynamic Psychiatry in Clinical Practice, 3 edition, Glen O Gabbard, MD, American Psychiatric Press, Inc., Washington, DC, 2000.

  19. Scheiber, Stephen C., M.D. "The Psychiatric Interview, Psychiatric History and Mental Status Exam". 193-223. Robert Hales, Stuart C. Yodofsky and John A. Talbert, eds. 1999. Textbook of Psychiatry. American Psychiatric Press

  20. Other Medicare contractor policies consulted in development of this draft:
    AdminaStar Federal carrier LMRP (Indiana [L7723], Kentucky [L7062])

    United Healthcare, policy numbers 99-13, 99-14, 99-15, 99-16, 99-17, 99-18, 99-19, 99-20, 99-21; pub. October, 1999, Medicare Provider News, No. 52 
 
Advisory Committee Meeting Notes 
Carrier Advisory Committee Meeting Date(s):

Indiana: 02/04/2008
Kentucky: 02/07/2008
New Jersey: 02/06/2008
New York: 01/30/2008

This coverage determination does not reflect the sole opinion of the contractor or contractor Medical Director. Although the final decision rests with the contractor, this determination is developed in consultation with representatives from Advisory Committee members and/or from various state and local provider organizations. 
 
Start Date of Comment Period 
01/17/2008 
 
End Date of Comment Period 
03/01/2008 
 
Start Date of Notice Period 
10/01/2010 
 
Revision History Number 
R7 
 
Revision History Explanation 
R7 (effective 10/01/2010): LCD revised for annual ICD-9-CM code updates for 2011. The “ICD-9-CM Codes That Support Medical Necessity” section of the policy is expanded as follows: ICD-9-CM codes 315.35, 784.52 and V62.85 have been added effective for dates of service on or after 10/01/2010. ICD-9-CM codes 315.35 and 784.52 have been added to the list of ICD-9 codes listed in the “Indications” section of the LCD under general coverage comments for CPT codes 90802 and all other psychotherapeutic procedure codes (codes 90810-90815, 90823-90829 and 90857) that are interactive techniques are covered for the interactive evaluation/treatment of children who are 16 years of age or younger. ICD-9-CM code V62.85 has been added to the list of ICD-9 codes listed in the “Indications” section of the LCD under general coverage comments for CPT code 90845. No notice period required and none given.

R6 (published 02/04/2010, effective 01/01/2010): In the “Indications” section of the LCD the following sentence, “Effective for dates of service on or after 01/01/2010, CPT code 90862 (pharmacologic management) or any successor code is not subject to the limitation,” has been revised to clarify that the change in the limitation is effective for claims received 01/01/2010, not for date of service. No notice period required and none given.

R5 (effective 01/01/2010): Based on Change Request (CR) 6686, Outpatient Mental Health Treatment Limitation, Item C in the “Indications” section has been revised to include information to phase out the outpatient mental health treatment limitation (the limitation) over a 5-year period, from 2010-2014. The following sentence has been revised from: “The outpatient mental health treatment limitation does not apply to consultations, diagnostic services, psychological testing, or inpatient hospital services” to: “The outpatient mental health treatment limitation does not apply to psychiatric diagnostic evaluations, diagnostic psychological and neuropsychological testing, or inpatient hospital services.”
The following language, “or any successor code”, has been added to the sentence: “Code M0064 (brief office visit for the purpose of monitoring or changing drug prescriptions) or any successor code is not subject to the limitation.” Effective for dates of service on or after 01/01/2010, the limitation no longer applies to CPT code 90862. CPT code 90862 has been removed from the following paragraph in Item C in the “Indications” section:
    When evaluation and management (E&M) codes are reported for treatment of psychiatric illness, except Alzheimer's Disease and related dementias (ICD-9-CM codes 290.0-290.43, 331.0, 331.2), the psychiatric limitation also applies to those services. For patients with Alzheimer's Disease or related dementias, if the primary treatment rendered is psychotherapy, the limitation applies to the therapy services. The limitation does not apply to an E&M service, or a non-psychotherapy service, rendered for the management of Alzheimer's Disease or related dementias.
No notice period required and none given.

R4 (effective 12/01/2009): Based on Change Request (CR) 6005, Comprehensive Outpatient Rehabilitation Facility (CORF) Services, CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12: 40.8 Psychological Services and 50-50.5 Outpatient Mental Health Treatment Limitation have been removed from the "CMS National Coverage Policy" and "Indications" section of the LCD. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12: 40.7 Social and/or Psychological Services has been added to the "CMS National Coverage Policy" and "Indications" section of the LCD. Bill type 75X - Clinic CORF has been removed from the "Bill Type Codes" section of the LCD. Minor corrections were made in the "Other Comments" section. Duplicate sources were removed from the "Sources of Information and Basis for Decision" section of the LCD. No notice period required and none given.

R3 (effective 10/01/2009): based on the annual ICD-9-CM updates for 2010, the "ICD-9-CM Codes That Support Medical Necessity" section of the article has been modified as follows: ICD-9-CM code 784.5 has been deleted and replaced with 784.51 and 784.59. The list of ICD-9-CM codes, under the comments for procedure code 90802, in the "Indications" section of the LCD, has also been revised to delete 784.5 and add 784.51 and 784.59. Minor changes were made to reflect current template language. No notice period required and none given.

06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this LCD as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this LCD as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

R2 (effective 03/01/2009): Source of revision – Internal – CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.5 has been revised and is now Section 20.5.1 based on Change Request #6320 January 1, 2009, January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS). Minor changes were made to reflect current template language. No notice period required and none given.

11/14/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00308 is removed from this LCD. Effective on this date, claims processing for Delaware is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state, and the claims processing for New York and Connecticut is performed by National Government Services under the J-13 MAC contract; carrier number 00805 is removed, and claims processing for New Jersey is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state.

R1: This revised LCD is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut – Part B the LCD is effective on August 1, 2008; for Upstate New York – Part B, the LCD is effective on September 1, 2008; and for New York and Connecticut – Part A, the LCD is effective on November 14, 2008. For New York – Part A (contract 00308), the content of this LCD is currently in effect but the LCD will be transferred to the J-13 contract number 13201 on November 14, 2008.

This LCD was revised during the Notice period of 05/15/2008-06/30/2008 to add the Jurisdiction 13 (J-13) MAC contractor numbers.

The CMS Statement of Work for the J13 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This NGS policy is being promulgated to the J13 MAC as the most clinically appropriate LCD within that jurisdiction.

The NGS roster of LCDs has been developed under the combined experience of seven Medicare contractor medical directors. The criteria for inclusion in this roster includes areas of identified CERT errors, especially repetitive errors; high volume/high dollar/pervasive problems; patient safety issues; potential for automation; beneficiary access to new technology; implementation of NCD; narrative medical necessity parameters for medical review and provider education; and CMS/law enforcement mandates.

NGS LCDs have undergone an advice and comment process from the providers in 23 states. This advice and comment process, the most comprehensive among all Medicare contractors, has ensured that NGS policies have benefited from the most in-depth and scientifically rigorous scrutiny. The NGS policy development process has resulted in the most clinically appropriate LCDs for providers and Medicare beneficiaries.

******************************

The following are administrative notes entered by the Medicare Coverage Database Contractor:


08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0900 was changed
8/1/2010 - The description for Revenue code 0901 was changed
8/1/2010 - The description for Revenue code 0914 was changed
8/1/2010 - The description for Revenue code 0915 was changed
8/1/2010 - The description for Revenue code 0916 was changed
8/1/2010 - The description for Revenue code 0918 was changed

8/1/2010 - Revenue code 0909 was deleted 
 
Reason for Change 
ICD9 Addition/Deletion
 
Last Reviewed On Date 
10/01/2010 
 
Related Documents 
Article(s)
A46199 - Outpatient Psychiatry and Psychology Services - Supplemental Instructions Article
 
LCD Attachments 
Outpatient Psychiatry and Psychology Services - Comment and Response (154,150 bytes)