Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27514

Psychiatric Therapeutic Procedures

L27514

CPT codes, descriptions and other data only are copyright 2007 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.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

45 CFR Section 164.501, Definitions.

CMS On-Line Manual Pub. 100-3, Chapter 1, Sections 30.1 and 70.1.

CMS On-Line Pub. 100-8, Chapter 3, Section 3.4.1.2.

CMS On-Line Manual Pub. 100-02, Chapter 15.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Psychiatric care includes the therapeutic services provided to a beneficiary for the treatment of mental, psychoneurotic, and personality disorders which are directed toward identifying specific behavior patterns, factors determining such behavior, and effective goal oriented therapies.

Providers of Mental Health Services

For approved providers of mental health services, the state licensure or authorization must specify that the provider’s scope of practice includes the provision of clinical psychotherapy for the treatment of mental illness. It is the responsibility of providers to be aware of their own state licensure laws and written agreements and/or protocols required, including changes as they occur.

Coverage for all non-physician practitioners is limited to services which they are authorized to perform by the state in which they practice.

Mental Health Services Under the "Incident to" Provision

"Incident to" services are defined in CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 60.1 as "services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness."

A billing provider may not hire and supervise a professional whose scope of practice is outside the hiring provider’s own scope of practice as authorized under State law, or whose professional qualifications exceed those of the supervising provider.

The training requirements and state licensure or authorization of individuals who perform psychological services are intended to ensure an adequate level of expertise in the cognitive skills required for the performance of diagnostic and therapeutic psychological services.

For psychotherapy services rendered under the "incident to" provision, the billing provider must evaluate the patient personally and must initiate a course of psychotherapy.

The appropriately trained therapists may then render follow-up psychotherapy services to the patient, incident to the billing provider’s services, which would then be monitored and supervised by the billing provider.

There must be continued active participation by the billing provider in the management of the course of the therapy, including documented review of the notes and brief direct contact with the patient to confirm the findings.

"Incident to" services are commonly furnished in the billing provider’s office and must be performed by employees, or leased employees, or independent contractors of the physician or legal entity billing and receiving payment for the services. The employee must be supervised directly by the billing provider, meaning the billing provider must be in the same office suite.

For all mental health "incident to" services rendered in the home, custodial care facility (33), adult day care center (99), or skilled nursing facility during a " non Part A stay" (incident to services are not covered for patients in a Part A stay), the billing provider (physician or CP) must be physically present and must personally supervise the individual performing the service. "Incident to" services are not covered for in-patient and outpatient hospital settings, including Partial Hospitalization, under Medicare Part B. (See CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 60)

Transmittal AB-03-037 on “Medicare Payments for Part B Mental Health Services” notes that “certain non physician practitioners such as clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants may have services furnished “incident to” their professional service.

Outpatient Mental Health Treatment Limitation

• Under Section 1833(c) of the Social Security Act and the CMS Manual System, Pub 100-1,Medicare General Information, Eligibility and Entitlement, Chapter 3, Sections 30-30.3 and Pub 100-4, Medicare Claims Processing, Chapter 12, Section 210, regardless of the actual expenses a beneficiary incurs for treatment of mental, psychoneurotic, and personality disorders in outpatient settings, payment is approved at 62.5% of the Medicare allowance for those services and paid at 80% of that approved amount.

• The limitation does not apply to consultations, diagnostic services, psychological testing or in-hospital services.

• The limitation applies to treatment services represented by the following 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, 90899, except in in-patient hospital (place of service 21).

• When evaluation and management (E&M) codes or code 90862 (pharmacologic management) are reported for treatment of psychiatric illness, except Alzheimer’s Disease or Senile Dementia (ICD-9-CM codes 331.0, 331.2, 290.0-290.43), the psychiatric limitation also applies to those services. For patients with Alzheimer’s Disease or Senile Dementia, 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 Senile Dementia.

Mental Health Services

Individual Psychotherapy

Individual Psychotherapy (90804-90829) is defined as treatment for mental illnesses and behavior disturbances in which the physician or therapist 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 techniques are not separate services specifically, but adjunctive measures in psychotherapy. They may be needed to aid the individual, the family, and the staff in managing the manifestations of the patient's mental illness.

Individual psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

While a variety of psychotherapeutic techniques are recognized for coverage under these codes, the service must be performed by a person licensed by the state to perform psychotherapy services.

Psychotherapy services (90804-90829) are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction. Procedure codes 90804-90829 should not be used to bill for ADL training and/or social interaction skills.

The patient must have the capacity to participate actively in all therapies prescribed, except for family therapy without the patient present (code 90846).

To benefit from psychotherapy, an individual must be cognitively intact to the degree that he/she can engage in a meaningful verbal interaction with the therapist (except for family therapy without the patient present, and where interactive psychotherapy is necessary). Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent establishment of a relationship with the therapist which allows insight-oriented, behavior-modifying or supportive therapy to be effective. The type and degree of dementia must be taken into account in planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a patient with dementia, the patient’s record should document that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

Procedure code(s) (90808-90809, 90814-90815, 90821-90822, 90828-90829) should not be routinely used. These codes are reserved for exceptional circumstances. In the event these services are rendered, the provider must document in the patient's medical record the medical necessity of the service and define the exceptional circumstances.

Family Psychotherapy

Family therapy (90846, 90847, 90849) is used to describe family participation in the treatment process of the patient. 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 for multiple families when similar dynamics are occurring due to a commonality of problems in the family members under treatment. The medical record must document the conditions described in this policy relative to codes 90846, 90847, and 90849.

Family psychotherapy (90847) primarily involves the treatment of the patient's condition, and not the treatment of each family member's problems. Therefore, this code represents a complete family session, payable only for the patient. This code is not to be used for the other family members involved in the family psychotherapy.

Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient's condition. The term "family" applies to traditional family members and "associates". Associates may be live-in companions or significant others. 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. This should not be used for taking a family history or E/M counseling services.

Counseling principally concerned with the effects of the patient's condition on the individual being interviewed would not be reimbursable as part of the physician's personal services to the patient.

Code 90849 has restrictive coverage by Medicare and would generally be noncovered. Such group therapy is directed to the effects of the patient's 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.

Group Psychotherapy

Group psychotherapy (90853) is defined as psychotherapy administered in a group setting with a trained group leader in charge of several patients (usually 4 to 9). Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction and support.

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, clinical psychologist, or clinical social worker and, in some states, certified nurse practitioners, or a clinical nurse specialist.

For Medicare coverage, group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, motion therapy, etc.

Group psychotherapy must be specified and prescribed by the psychiatric practitioner developing the treatment plan as an integral part of an active treatment plan for which it is directly related to the patient's identified condition/diagnosis.

Psychoanalysis

Psychoanalysis (90845) is the practice of psychoanalysis which uses a special technique to gain insight into a patient's unconscious motivations and conflicts and is a different therapeutic modality than psychotherapy.

The medical record must document the indications for psychoanalysis, description of the transference and that psychoanalytic techniques were used. The physician using this technique must be trained and credentialed in its use. It is not time-related, but the code may be billed once for each daily session regardless of the time involved. The Relative Value Units assigned to this code are based on a 45-60 minute session. Psychoanalysis is generally considered unsuitable for psychoses.

Interactive Individual Psychotherapy

Interactive individual psychotherapy (90810-90815, 90823-90829) and interactive group psychotherapy (90857) codes are used when the patient or patients in the group setting do not have the ability to interact by ordinary verbal communication.

In interactive therapy, the physician or therapist 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 in the medical record must include the need for interactive therapy. Other catatonic states may be covered if documentation is submitted with the claim.

Coverage also includes interactive examinations of patients with a primary psychiatric diagnosis as listed under codes (90804-90809 and 90816-90822) excluding the dementias (ICD-9-CM codes 290.0-290.9) and sleep disorders (ICD-9-CM 307.40-307.49) and one of the following conditions: developmental speech or language disorder, conductive hearing loss (total), sensorineural hearing loss (total), mixed conductive and sensorineural hearing loss (total), deaf mutism, other specified forms of hearing loss, aphasia, voice disturbance, aphonia, and other speech disturbance (dysarthria, dysphasia).

When the primary psychiatric diagnosis does not indicate the medical necessity for interactive psychotherapy, one of the secondary diagnoses listed in the preceding paragraph or the reason why the patient does not have the ability to interact through normal verbal communication channels must be documented in the patient's medical records.

Other Psychiatric Services or Procedures

Narcosynthesis (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.

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, dosage administered, and whether the technique was effective or non-effective.

NOTE: 90865 is restricted to physicians, (M.D./D.O. only).

Limitations:

Individual psychophysiological therapy incorporating biofeedback training by any method (face-to-face with the patient (90875 and 90876)) is noncovered. Medicare does not cover biofeedback for the treatment of psychiatric disorders.

Medically unnecessary services are not covered by Medicare.

Medical record documentation does not verify that the services described under the CPT/HCPCS codes listed on this policy were provided, or that the services did not fall within the guidelines of this LCD.

Services were not provided by a qualified provider (as defined by Medicare).

Individual and group psychotherapy services are not considered medically necessary for the patient with severe or profound mental retardation (ICD-9-CM codes 318.1, 318.2, and 319). Severe mental retardation is defined as an IQ 20-34 and profound mental retardation is defined as an IQ under 20.

These services are not considered medically necessary if a review of medical records indicates that dementia (organic brain syndrome) and Alzheimer's Disease (ICD-9-CM codes, 290.0-290.9, 331.0-331.2) have produced a severe enough cognitive defect to prevent psychotherapy from being effective.

The duration of psychotherapy must be individualized for every patient. Prolonged treatment may warrant medical necessity review. The provider of service must document in the patient’s record the medical necessity for continued (prolonged) treatments.

Group therapy (90853, 90857) sessions should not exceed 10 participants, and should be at least 45 to 60 minutes in duration. While a video or movie may be used as an adjunct to the sessions, this modality should not be used as a replacement for the therapist’s active participation and the majority of the session should involve the interaction between the participants and the therapist leading the session. If group psychotherapy is provided to a patient with dementia, the patient’s record should document that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

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

All psychotherapy services described in this section are payable to psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse practitioners, and clinical nurse specialists with these exceptions:

Clinical social workers (CSWs and LCSWs) are not eligible for payment for inpatient services represented by these codes:

• 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, and 90829, except for patients in a nursing home who are not in a Part A stay.
• CNSs, and NPs are not eligible for payment for psychoanalysis (90845).

Psychotherapy codes that include a medical evaluation and management service (90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829) are payable only to physicians, and qualified CNSs and NPs. Each element of these services (therapy and E&M) must be reasonable and necessary and should be documented in the patient’s records.

Mental Health Care (Inpatient), Mental Health Care (Outpatient), Mental Health Care (Partial Hospitalization)

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
4. 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). Per Privacy Rule 45 CFR § 164.501, contractors may not request that a provider submit psychotherapy notes. However, physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes. Providers are responsible for extracting the information needed to support that the claim is reasonable and necessary.
   
5. The Privacy Rule in 45 CFR § 164.501 defines psychotherapy notes as notes recorded by a mental health professional that document or analyze the contents of a counseling session and that are separated from the rest of a medical record. The definition of psychotherapy notes expressly excludes all of the following: Medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date.
   
6. Medical record documentation maintained by the provider must indicate the medical necessity of the psychotherapy (individual, group, and family) including the following:the presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to significantly alter baseline functions; the time spent in each psychotherapy encounter;documentation that therapeutic interventions, such as behavior modification, supportive interaction, and discussion of reality were applied in an attempt to produce therapeutic change; the patient's capacity to participate in and benefit from psychotherapy; the estimated duration of treatment in terms of number of sessions required; and the target symptoms, the goals of therapy and methods of monitoring outcome, and why the chosen therapy is the appropriate treatment modality either in lieu of or in addition to another form of psychiatric treatment.
   
7. The medical record documentation for psychotherapy must be clear and concise. Statements such as "supportive psychotherapy given" are not adequate. A clear and detailed description of what the psychotherapy entailed and how it is addressing the presenting problem of the patient should be evident. Time spent in each psychotherapy encounter should also be delineated.
   
8. For group therapy, progress notes should indicate the degree of patient participation, interaction with group members and leader, the reaction of the patient to the group, and the group's reaction to the patient. The medical record should also reflect the changes or lack of changes in patient symptoms and/or behavior as a result of the group psychotherapy.
   
9. Procedure code(s) (90808-90809, 90814-90815, 90821-90822, 90828-90829) are reserved for exceptional circumstances. The documentation in the medical record must reflect the medical necessity of the service and outline the exceptional circumstances.
   
10. For an acute problem, there should be documentation that the treatment is expected to improve the health status or function of the patient. For chronic problems there must be documentation indicating that stabilization or maintenance of health status or function is expected.
    
     

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27514

05/22/2008

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