|LCD for Outpatient Psychiatry and Psychology Services (L26895)|
|Contractor Type |
|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.
A. Approved Providers of Service
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:  incident to a physician's service, and  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:
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:
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:
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
784.52 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)
Information in this part of the policy has been subdivided into three (3) sections. These sections address the following CPT/HCPCS procedure codes:
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
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:
296.23 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
296.33 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
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:
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.
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.
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.
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:
300.12 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
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:
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.
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:
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).
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] and 1862[a] 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).