Revised LCDs Effective January 01, 2006
Psychiatry and Psychological Services and “Incident To” These Services
Noridian Administrative Services, LLC
Contractor InformationContractor Name / Noridian Administrative Services, LLC
Contractor Number / 00820 – CO, ND, SD, WY
00821 – AK, AZ, HI, NV, OR, WA
00826 – IA
Contractor Type / Carrier
LCD Information
LCD Database ID Number / L21717 – CO, ND, SD, WY
L21719 – AK, AZ, HI, NV, OR, WA
L21720 – IA
LCD Version Number
LCD Title / Psychiatry and Psychological Services and “Incident To” These Services
Contractor's Determination Number / B2004.10 R1
AMA CPT / ADA CDT Copyright Statement / CPT codes, descriptions and other data only are copyright 2005 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 / Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
CMS Medicare Benefit Policy Manual, Chapter 15, Section 60.1 [formerly Medicare Carriers Manual (MCM) 2050.1]. This section of the manual addresses “Incident to” services.
CMS Medicare Benefit Policy Manual, Chapter 15, Section 80.2 [formerly Medicare Carriers Manual (MCM) 2070.2]. This section of the manual addresses independent psychologists.
CMS Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 70.1 (formerly Medicare Coverage Issues Manual 35-14).
Primary Geographic Jurisdiction / AK
AZ
CO
HI
IA
ND
NV
OR
SD
WA
WY
Oversight Region / Region X
CMS Consortium / Western
Original Determination Effective Date / For services performed on or after 12/31/2005
Original Determination Ending Date
Revision Effective Date / For services performed on or after 01/01/2006
Revision Ending Date
Indications and Limitations of Coverage and/or Medical Necessity / Information in this part of the policy had been divided into six (6) sections. These sections address each individual CPT/HCPCS procedure code.
I. General Clinical Psychiatric Diagnostic or Evaluative Interview Procedures
II. Special Clinical Psychiatric Diagnostic or Evaluative Procedures
III. Psychiatric Therapeutic Services
IV. Psychiatric Somatotherapy
V. Other Psychiatric Disorders
VI. Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing)
Section I: General Clinical Psychiatric Diagnostic or Evaluative Interview Procedures:
Description: A psychiatric diagnostic interview examination (90801) includes a history, mental status exam, and a disposition, as well as ordering and medical interpretation of laboratory or other medical diagnostic studies. The diagnostic interview may include communication with family or other sources, and in certain circumstances, other informants will be seen in lieu of the patient. The psychiatrist obtains a complete medical and psychiatric history from the patient and/or family and establishes a tentative diagnosis. The patient's capacity to work psychotherapeutically is also evaluated to determine how willing he or she is to work toward a positive solution to the problem. The patient's condition determines the extent of the mental status examination during the diagnostic interview. The psychiatrist is looking for symptoms of psychopathology in the patient's general appearance, attitude toward the examiner, and overall behavior. In addition, the speech and stream of talk, emotional reaction and mood, perception and thought content, and cognition may be evaluated.
An evaluation and management (E/M) service may be substituted for the initial interview procedure, including consultation codes (CPT99241-99255), provided all required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, providing a written opinion and/or advice. They do not include psychiatric treatment, though such treatment may be initiated on the same day as the consultation.
A psychiatric diagnostic interview examination is usually covered once, when a provider first sees a patient for a suspected or diagnosed psychiatric illness. It may be utilized again for the same patient if a new episode of illness occurs or is thought to have occurred, or on admission, or re-admission to inpatient status due to complications of the underlying condition. If the provider is unable to perform the psychiatric diagnostic interview examination at the initial encounter because of the patient's mental or physical condition, a code should be selected for the initial encounter based specifically on what services/procedures the psychiatrist did perform or provide. If, after completing an assessment it is concluded that no mental illness is present, the visit may be coded with ICD-9-CM V71.09 (Observation for suspected mental condition - Other suspected mental condition).
Section II: Special Clinical Psychiatric Diagnostic or Evaluative interview examination.
Description: The interactive psychiatric diagnostic interview examination (90802) is typically furnished to children. It involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a patient who has not yet developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. This code may also be used for the initial evaluation of patients whose ability to communicate is impaired by an expressive or receptive language impairment.
The Interactive Psychiatric Diagnostic Interview Examination (90802) includes the same components as the Psychiatric Diagnosis Interview Examination, which includes history, mental status, disposition, and other components as indicated. However, in the interactive examination, the physician 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 deaf person or one who does not speak English.
Documentation: The medial record must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels. If the patient is incapable of communication by any means this code may not be billed.
Section III: Psychiatric Therapeutic Procedures
Description: Procedure code 90865 (Narcosynthesis for psychiatric diagnostic and therapeutic purposes [e.g., sodium amobarbital {Amytal} interview]) 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.
Use of code 90865 is restricted to physicians.
Documentation: The medical record should document the medical necessity of this procedure, i.e., the patient had difficulty verbalizing about psychiatric problems without the aid of the drug. The record should also document the specific pharmacological agent, dose and route of administration, and whether the technique was effective or non-effective.
Description: Procedures 90804 through 90829
Psychotherapy is defined in CPT as “the treatment for mental illness and behavioral disturbances in which the physician 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.”
Behavior modification is not a separate service specifically, but rather an adjunctive measure in psychotherapy. It is not expected to be a frequent or ongoing service, but may need to be repeated at reasonable intervals to aid the individual, the family, and the staff in managing the manifestations of the patient’s mental illness.
These covered services may be performed only by a person authorized by the state to perform psychotherapy services. Medicare coverage of procedure codes 90804-90829 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction, therefore, procedure codes 90804-90829 should not be used to bill for ADL training and/or social interaction skills.
Note: Procedure codes 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, and 90829 include medical evaluation and management (E/M) services which include continuing medical diagnostic evaluation as well as pharmacologic management. Therefore, pharmacologic management (90862) and E/M service codes may not be billed separately on the same day as a psychotherapy service by the same physician.
Guidelines For Procedure Codes 90804-90829:
1. Individual psychotherapy codes should be used only when the focus of the treatment encounter involves psychotherapy. Psychotherapy codes should not be used as generic psychiatric service codes when another code, such as an E/M or pharmacologic management code, would be more appropriate.
2. Prolonged treatment must be medically necessary and may be subject to medical review. Documentation must be present in the medical record indicating the necessity for an extended number of treatment visits.
3. Procedure codes 90808, 90809, 90814, 90815, 90821, 90822, 90828, and 90829 (approximately 75-80 minutes) should not be routinely used. They are reserved for exceptional circumstances. The provider must document in the patient’s medical record the medical necessity of these services and define the exceptional circumstances.
4. Medicare will not accept psychiatric therapy procedure codes 90804-90829 being billed on the same date of service as an evaluation and management (E/M) service, by the same physician or mental health profession group. The single exception is that a consultation may be billed at the initial visit, and, in addition, psychotherapy codes which do not include medical evaluation and management services (90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828) may be billed on the same date of service, if such services are medically indicated and performed.
5. Psychotherapy services are not covered when documentation indicates that Dementia (ICD-9-CM codes 290.0, 290.20-290.9, 331.0-331.2) has produced a severe enough cognitive defect to prevent psychotherapy to be effective. Severe and profound mental retardation (ICD-9-CM codes 318.1 and 318.2) are never covered for psychotherapy services. In such cases, rehabilitative, evaluation and management (E/M) codes or pharmacologic management codes should be reported.
6. For psychotherapy sessions lasting longer than 90 minutes, use CPT code 90899 with a description in Item 19 of the CMS-1500 claim form or electronic equivalent. When requested, please send Medicare a copy of the patient’s medical record, documenting the face-to-face time spent with the patient and the medical necessity for the extended time.
7. These codes should not be used as generic psychiatric service codes when other codes such as an Evaluation & Management service or pharmacologic codes would be more appropriate.
8. When CPT codes 90804-90829 are performed by a physician, CPT code 90862 is not a separate or additional benefit, but is included in the psychotherapy codes
Description: Psychoanalysis (90845) refers to the use of investigative techniques to gain insight into a person's unconscious motivations, conflicts, and symbols to effect a change in maladaptive behavior. This code refers to the practice of psychoanalysis and should not be confused with or used for psychotherapy.
90845 is not time related, but is billed once for each necessary daily session regardless of the time involved. In the rare circumstance where psychoanalysis is used for a psychosis, the record must document the necessity in terms of expected outcome in contrast with other available therapeutic options.
Description: Procedure codes 90846, 90847, 90849 are used for Family Therapy, a specialized therapeutic technique for treating the identified patient’s mental illness by intervening in a family system in such a way as to modify the family structure, dynamics and interactions which exert influence on the patient’s emotions and behavior. Family sessions are conducted face to face with family members, with (90847) or without (90846) the patient present. Code 90849 is intended for group therapy sessions for multiple families when similar dynamics are occurring due to a commonality of problems in the family members under treatment.
Comments: The CMS Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 70.1 (formerly Medicare Coverage Issues Manual 35-14), states that family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient’s condition. Examples are as follows:
1. When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members (CPT 90847).
2. 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).
Procedure codes 90846-90847 represent psychotherapy services for treatment of mental disorders. They should not be used to code taking a family history or E/M counseling services. Further, 90846, family psychotherapy without the patient present, should rarely be billed and, when provided, must always be directed towards the patient’s condition, not the family’s problems with the patient.
Code 90849 has restrictive coverage by Medicare and would generally be non-covered. Such group therapy is directed to the effects of the patients’ condition on the family, and does not meet Medicare’s standards of being part of the physician’s personal services to the patient. If such is not the case, individual consideration may be given if documentation is submitted.
Description: Psychotherapy administered in a group setting (90853) with a trained group leader in charge of several patients. The psychotherapy process may be conducted with several patients in a group setting. The personal dynamics of an individual may be discussed by the group and the dynamics of the group may be explored at the same time. Interpersonal interactions, support, emotional catharsis, and reminiscing are other examples of the processes explored in group settings.
Comments: Group therapy, since it involves psychotherapy, must be led by a person who is authorized by state statute to perform this service. This will usually mean a psychiatrist, psychologist, or clinical social worker or, in some states, certified nurse practitioner, clinical nurse practitioner, clinical nurse specialist, or qualified mental health specialist. For Medicare Part B coverage, group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, motion therapy, etc.
Description: Codes 90810-90815, 90823-90829 and 90857 are used when the patient, or patients in the group setting, does not have the ability to interact by ordinary verbal communication therefore non-verbal communication skills are employed, or an interpreter may be necessary. The guidelines in the Description, Documentation, and Comments sections under CPT 90802 apply to codes 90810-90815, 90823-90829, and 90857.