LCD L34353: Outpatient Psychiatry and Psychology Services

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

• Physicians (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).

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:

• 2010-2011 = 68.75 percent;

• 2012 = 75 percent;

• 2013 = 81.25 percent; and,

• 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 procedures for psychiatric therapy evaluation codes except in in-patient hospital and inpatient psychiatric facility.

When evaluation and management (E&M) codes are reported for treatment of psychiatric illness, except Alzheimer's Disease and related dementias, 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, pharmacologic management or any successor code is not subject to the limitation.

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 seven (7) sections. These sections address the following procedures:

• Psychiatric Diagnostic Procedures

• Interactive Complexity

• Psychotherapy

• Psychotherapy in Crisis

• Psychiatric Somatherapy

• Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing)

• Other Psychiatric Services or Procedures

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]).

Section I: Psychiatric Diagnostic Interview Examination :

Description: The psychiatric diagnostic procedure codes require 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: This service may be reported once per day and not on the same day as an evaluation and management service performed by the same individual for the same patient.

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.

Section II: Interactive Complexity :

Description: :“Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients.” (CPT 2013, Professional Edition, p.483)

The interactive complexity component code may be used in conjunction with codes for diagnostic psychiatric evaluation and psychotherapy, psychotherapy when performed with an evaluation and management service, and group psychotherapy.

The code is used principally to evaluate children and also adults who do not have the ability to interact through ordinary verbal communication. 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.

• Interactive complexity may also be used in the evaluation of adult patients with organic mental deficits, or for those who are catatonic or mute.

• Interactive complexity may be reported with psychotherapy when at least one of the following is present:

• Maladaptive communication (eg, high anxiety, high reactivity, repeated questions or disagreement)

• Emotional or behavioral conditions inhibiting implementation of treatment plan

• Mandated reporting/event exists (eg, abuse or neglect) or

• Play equipment, devices, interpreter, or translator required due to inadequate language expression or different language spoken between patient and professional.

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.

Section III: Psychotherapy Psychiatric Therapeutic Procedures :

Information in this part of the policy has been subdivided into three (3) sections. These sections address the following procedures:

• Represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy

• Represent psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy

• Represents narcosynthesis for psychiatric diagnostic and/or therapeutic purposes

A. Codes representing insight oriented, behavior modifying, supportive, and/or interactive psychotherapy

Description: Procedures for psychotherapy are defined as "the treatment for mental illness and behavioral disturbances in which the physician or other qualified health care professional through definitive therapeutic communication attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development." (CPT 2013, Professional Edition, p.485)

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 for psychotherapy are timed codes that are used to represent the actual time spent with the patient. There are add on codes that should be used in conjunction with evaluation and management (E/M) codes.

For psychotherapy sessions lasting 90 minutes or longer, the appropriate prolonged service code should be used . 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.

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 for psychiatric therapy does not include teaching grooming skills, monitoring activities of daily living (ADL), recreational therapy (dance, art, play) or social interaction. Therefore, these should not be used to bill for ADL training and/or teaching social interaction skills.

Psychotherapy codes that include an evaluation and management component are payable only to physicians, NPPs 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 representing psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy

Psychoanalysis:

Description: Procedure code 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. The code for this service is not time defined, but is usually 45 to 50 minutes and is billed once for each daily session.

Family Psychotherapy:

Description: Procedure codes that 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. Family Psychotherapy can be done without or with the patient is present. 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 for family psychotherapy.

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.

• 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.

The term "family" may apply to traditional family members, live-in companions, or significant others involved in the care of the patient. The codes representing these services are not timed but are typically 45 to 60 minutes in duration.

These services 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.

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, multiple-family group psychotherapy does not meet Medicare's standards of being a therapy primarily directed toward treating the beneficiary's condition. These may be approved on an individual consideration basis.

N/A