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Local Coverage Determination (LCD)

Health and Behavior Assessment/Intervention

L37638

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37638
Original ICD-9 LCD ID
Not Applicable
LCD Title
Health and Behavior Assessment/Intervention
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 01/29/2018
Revision Effective Date
For services performed on or after 01/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/14/2017
Notice Period End Date
01/28/2018

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The Health and Behavioral Assessment, Initial and Reassessment, and Intervention services may be considered reasonable and necessary for the patient who meets all of the following criteria:

  • The patient has an underlying physical illness or injury, and

  • There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and

  • The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and

  • The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living (ADLs), and

  • The assessment is not duplicative of other provider assessments.

In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well-being.

Health and Behavioral Intervention with the family and patient present is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient.

Limitations

Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:

  • Does not have an underlying physical illness or injury, or
  • For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
  • Does not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of:

- Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective

- Delirium

- Severe and profound mental retardation

- Persistent vegetative state/no discernible consciousness

- Impaired mental status such as disorientation to person, time, place, purpose; inability to recall current season, location of own room, names and faces; inability to recall being in a nursing home or skilled nursing facility; or does not require psychological support to successfully manage their physical illness through identification of the barriers to the management of physical disease and ADLs.

Examples of Health and Behavioral Intervention services that are not covered and are not considered reasonable and necessary include:

  • To provide family psychotherapy or mediation
  • To maintain the patient's or family's existing health and overall well-being
  • To provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
  • Individual social activities
  • Teaching social interaction skills
  • Socialization in a group setting
  • Vocational or religious advice
  • Tobacco or caffeine withdrawal support
  • Teaching the patient simple self-care
  • Weight loss management
  • Maintenance of behavioral logs
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

For the initial assessment, documentation in the medical record must include evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:

  • Date of initial diagnosis of physical illness, and
  • Clear rationale for why assessment is required, and
  • Assessment outcome including mental status and ability to understand and respond meaningfully, and
  • Goals and expected duration of specific psychological intervention(s), if recommended.

For reassessment, detailed progress notes to support medical necessity must include the following elements:

  • Date of change in mental or physical status;
  • Sufficient rationale for why reassessment is required, and;
  • A clear indication of any precipitating events that necessitate reassessment.

For the intervention service, evidence to support medical necessity must include, at a minimum, the following elements:

  • Evidence that the patient has the capacity to understand and to respond meaningfully;
  • Clearly defined psychological intervention planned;
  • The goals of the psychological intervention;
  • The expectation that the psychological intervention will improve compliance with the medical treatment plan;
  • The response to the intervention, and;
  • Rationale for frequency and duration of services.

For all claims, the time duration (stated in minutes) spent in the Health and Behavioral Assessment or Intervention encounter must be documented in the record.

All coverage criteria must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

Utilization Guidelines

Initial assessment should not exceed 1 hour (4 units).

Reassessment should not exceed 1 hour (4 units).
Sources of Information

N/A
Bibliography

American Medical Association. Coding consultation: Questions and answers. CPT Assistant. 2004;14(2):11.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
01/01/2024 R7

Under Associated Information subheading Documentation Requirements revised the first sentence to state “For the initial assessment, documentation in the medical record must include evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements.”
  • Provider Education/Guidance
10/10/2019 R6

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Health and Behavior Assessment/Intervention A56562 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
05/16/2019 R5

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been moved into the related Billing and Coding: Health and Behavior Assessment/Intervention A56562 article and removed from the LCD. 

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
09/13/2018 R4

ICD-10 codes referenced in Revision #3 were not added as new codes; they were broken out from the range F01.50 - F99. All ICD-10 codes that are no longer listed in the LCD under ICD-10 Codes that DO NOT Support Medical Necessity may be considered covered as of 9/13/18.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Other
09/13/2018 R3

Under ICD-10 Codes that DO NOT Support Medical Necessity Group 1: Codes the following codes have been added: F11.120, F11.121, F11.122, F11.129,F11.150, F11.151, F11.159, F11.220, F11.221, F11.222, F11.229, F11.250, F11.251, F11.259, F11.920, F11.921, F11.922, F11.929, F11.950, F11.951, F11.959, F12.120, F12.121, F12.122, F12.129, F12.150, F12.151, F12.159, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.920, F12.921, F12.922, F12.929, F12.950, F12.951, F12.959, F13.120, F13.121, F13.129, F13.150, F13.151, F13.159, F13.220, F13.221, F13.229, F13.250, F13.251, F13.259, F13.920, F13.921, F13.929, F13.950, F13.951, F13.959, F14.120, F14.121, F14.122, F14.129, F14.150, F14.151 ,F14.159, F14.220, F14.221, F14.222, F14.229, F14.250, F14.251, F14.259, F14.920, F14.921, F14.922, F14.929, F14.950, F14.951, F14.959, F15.120, F15.121, F15.122, F15.129, F15.150, F15.151, F15.159, F15.220, F15.221, F15.222, F15.229, F15.250, F15.251, F15.259, F15.920, F15.921, F15.922, F15.929, F15.950, F15.951, F15.959, F16.120, F16.121, F16.122, F16.129, F16.150, F16.151, F16.159, F16.220, F16.221, F16.229, F16.250, F16.251, F16.259, F16.920, F16.921, F16.929, F16.950, F16.951, F16.959, F17.220, F17.221 F17.229, F18.120, F18.121, F18.129, F18.150, F18.151, F18.159, F18.220, F18.221, F18.229, F18.250, F18.251, F18.259, F18.920, F18.921, F18.929, F18.950, F18.951, F18.959, F19.120, F19.121, F19.122, F19.129, F19.150, F19.151, F19.159, F19.220, F19.221, F19.222, F19.229, F19.250, F19.251, F19.259, F19.920, F19.921, F19.922, F19.929, F19.950, F19.951, F19.959.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
  • Public Education/Guidance
02/26/2018 R2 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R1

The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.

  • Other
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
10/15/2024 01/01/2024 - N/A Currently in Effect You are here
10/04/2019 10/10/2019 - 12/31/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Health and Behavior
  • Behavior

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