Article

Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article

A52825

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
National Government Services, Inc.	MAC - Part A	06101 - MAC A	J - 06	Illinois
National Government Services, Inc.	MAC - Part B	06102 - MAC B	J - 06	Illinois
National Government Services, Inc.	MAC - Part A	06201 - MAC A	J - 06	Minnesota
National Government Services, Inc.	MAC - Part B	06202 - MAC B	J - 06	Minnesota
National Government Services, Inc.	MAC - Part A	06301 - MAC A	J - 06	Wisconsin
National Government Services, Inc.	MAC - Part B	06302 - MAC B	J - 06	Wisconsin
National Government Services, Inc.	A and B and HHH MAC	13101 - MAC A	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13102 - MAC B	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13201 - MAC A	J - K	New York - Entire State
National Government Services, Inc.	A and B and HHH MAC	13202 - MAC B	J - K	New York - Downstate
National Government Services, Inc.	A and B and HHH MAC	13282 - MAC B	J - K	New York - Upstate
National Government Services, Inc.	A and B and HHH MAC	13292 - MAC B	J - K	New York - Queens
National Government Services, Inc.	A and B and HHH MAC	14111 - MAC A	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14112 - MAC B	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14211 - MAC A	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14212 - MAC B	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14311 - MAC A	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14312 - MAC B	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14411 - MAC A	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14412 - MAC B	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14511 - MAC A	J - K	Vermont
National Government Services, Inc.	A and B and HHH MAC	14512 - MAC B	J - K	Vermont

Article Information

General Information

Article ID
A52825

Article Title
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article

Article Type
Article

Original Effective Date
10/01/2015

Revision Effective Date
01/01/2024

Revision Ending Date
N/A

Retirement Date
N/A

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Article Guidance

Article Text

Abstract:

"Incident to" a physician's professional services means that the services or supplies are 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. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.1) The "incident to" provision may also apply to coverage for psychological services furnished "incident to" the professional services of certain non-physician practitioners including clinical psychologists, nurse practitioners, and clinical nurse specialists (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.2). Section 1862(a)(1)(A) of the Social Security Act governs payment for the provision of medical care to Medicare beneficiaries.

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. Therefore, only the types of individuals listed later in this policy are considered qualified to perform medically necessary psychological services addressed in this policy. Delegation of diagnostic and therapeutic psychological services to personnel not performing within the scope of practice as authorized by state law, under the "incident to" provision, would bypass the safeguards afforded by professional credentialing and state licensure requirements. Such delegated services under the "incident to" provision would be inappropriate, unreasonable, and medically unnecessary, and therefore not covered by Medicare.

Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.1B. To be considered an employee (auxiliary personnel) for purposes of this section, the nonphysician performing an "incident to" service is defined as any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician or legal entity that employs or contracts with the physician. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.1B).

Indications and Limitations:

For psychology services rendered under the "incident to" provision, the billing provider must first evaluate the patient personally and then initiate the course of treatment. The appropriately trained therapists may then render psychological services to the patient under the billing provider's general supervision.

While a variety of psychiatric/psychotherapeutic techniques are recognized for coverage, the services must be performed by persons authorized by Medicare and licensed by their state to render these services.

Only the types of practitioners listed below, when they are performing within their scope of clinical practice as authorized under state law, are qualified to perform the indicated diagnostic and/or therapeutic psychological services under the "incident to" provision.

Doctorate or Masters level Clinical Psychologist: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90880, 90899
Doctorate or Masters level Clinical Social Worker: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
Clinical Nurse Specialist (CNS): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
Nurse Practitioner (NP): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
Marriage and Family Therapist (MFT): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451
Mental Health Counselor (MHC): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451

The psychological services referenced in the above HCPCS codes may only be delegated to employees who qualify for one of the categories of individuals listed above. For example, a psychiatrist may hire a clinical social worker to perform services designated by the HCPCS codes listed in #2 above. Individuals who are performing services "incident to" a qualified Medicare practitioner are not required to be separately enrolled as an independent practitioner in Medicare.

It is not permissible for the billing provider to hire and supervise a professional whose scope of practice is outside the provider's own scope of practice as authorized under State law, or whose professional qualifications exceed those of the "supervising" provider. For example, a certified nurse-midwife (CNM) may not hire a psychologist and bill for that psychologist's services under the "incident to" provision, because a psychologist's services are not integral to a CNM's personal professional services and are not regularly included in the CNM's bill. Even though sections 1861(s)(2)(l) and 1861(gg) (l) of the Social Security Act authorize coverage for services furnished "incident to" a CNM's services, psychological services are not commonly furnished in CNM's offices nor within their scope of practice. Similarly, even though section 1861(s)(2)(K)(iv) authorizes coverage for services furnished "incident to" a physician assistant's services, a physician assistant would not be qualified to supervise psychological services performed by the types of individuals listed above.

Individuals who are not licensed or otherwise authorized by state law to provide psychological services may not provide psychological services under the "incident to" provision. This level of professional credentialing is necessary to furnish appropriate medically necessary services under the "incident to" provision.

Psychological services furnished to Medicare beneficiaries under the "incident to" provision by individuals other than those listed above are not covered. (Note: the standards for professional credentialing are higher for these services billed to Medicare Part B than for similar services performed by other mental health professionals not under the "incident to" provision and billed to Medicare Part A. Under the "incident to" provision, services are performed in the place of the billing provider. In order for services performed and billed under the "incident to" provision to be commensurate with the services performed by the billing provider, and therefore medically necessary, this higher standard of professional credentialing is necessary.)

Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.1B. This also applies to the services of certain non - physician practitioners who are being licensed by the states under various programs to assist or act in the place of the physician, including nurses, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors and other therapists. General Supervision - means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15). Services and supplies incident to a physician’s service in a physician directed clinic or group association are generally the same as those described for the office setting (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.3).

For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of physician-employed auxiliary personnel as services incident to physicians' services under section 1891(s)(2)(A) of the Act. Such services can be covered only under the hospital outpatient or inpatient benefit and payment for such services can be made to only the hospital by a Medicare Part A MAC (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60).

For "incident to" services to be covered when a physician's office is in an institution, the auxiliary medical personnel must be members of the office staff rather than of the institution's staff, and the cost of supplies must represent an expense to the physician's office practice. In addition, services performed by the employees of the physician outside the "office" area must be generally supervised by the physician. (In any setting, of course, supervision of auxiliary personnel in and of itself is not considered a "physician's professional service" to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to supervision, the physician must perform or have performed a personal professional service to the patient to which the services of the auxiliary personnel could be considered an incidental part). Denials for failure to meet any of these requirements would be based on §1861(s)(2)(A) of the Act. (CMS Pub 100-03; Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, 70.3)

If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than a hospital or SNF), their services are covered incident to a physician's service only if there is general supervision.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

General Coding Guidelines for Psychiatry and Psychology Services:

Individual psychotherapy codes should be used only when the focus of treatment involves individual psychotherapy. These codes should not be used as generic psychiatric service codes when other codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.

Charges for certain psychiatric services provided by hospital outpatient departments are submitted to the Part A MAC. Services of physicians, clinical psychologists, physician assistants, nurse practitioners, and clinical nurse specialists are billed to the Part B MAC. Services furnished incident to the professional services of clinical psychologists to hospital patients remain bundled with the facility services for payment purposes, with payment made to the hospital for such "incident to" services.

For claims submitted to the Part B MAC:

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

Claims for Psychological Services Coverage Under the "Incident to" Provision are payable under Medicare Part B in settings other than a hospital or to a resident of a skilled nursing facility who are in a Part A stay.

For claims submitted to the Part A MAC:

Hospital Inpatient Claims:

The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)

Hospital Outpatient Claims:

The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.

Information on state specific providers licensed or authorized to provide psychological services "incident to" a physician, clinical psychologist, clinical nurse specialist, or nurse practitioner (as defined in the "Indications" section above), can be found at respective State Web sites regarding the licensing and certification of mental health providers.

Sources of Information:

CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA):

Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1861(s)(2)(A) of Title XVIII of the Social Security Act defines 'medical and other health services' as "any of the following items or services: services and supplies (including drugs and biologicals which cannot, as determined in accordance with regulations, be self – aministered) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;"

Sections 1861(s)(2)(l) and 1861(gg)(l) of Title XVIII "incident to" a certified nurse midwife's(CNMW's)services.

Section 1861(s)(2)(K)(iv) of Title XVIII of the Social Security Act authorizes coverage for services furnished "incident to" a physician assistant's services.

Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

60.1 Incident to Physician's Professional Services

60.2 Services of Nonphysician Personnel Furnished Incident to Physician's Services

60.3 Incident to Physician's Service in Clinic

60.4 Services Incident to a Physician's Service to Homebound Patients under General Physician Supervision

160 Clinical Psychological Services

170 Clinical Social Worker (CSW) Services

210 Clinical Nurse Specialist (CNS) Services

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:

70.3 Physician's Office Within an Institution - Coverage of Services and Supplies Incident to a Physician’s Services

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

110 Physician Assistant (PA) Services Payment Methodology

110.3 PA Billing to Carrier

120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services.

120.1 Direct Billing and Payment for Nonphysician Practitioner Services Furnished to Hospital Inpatients and Outpatients

150 Clinical Social Worker (CSW) Services

160 Independent Psychologist Services

160.1 Payment for Independent Psychologist Services

170 Clinical Psychologist Services.

170.1 Payment for Clinical Psychologist Services

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
012x	Hospital Inpatient (Medicare Part B only)
013x	Hospital Outpatient
085x	Critical Access Hospital

Revenue Codes

Code	Description
0900	Behavioral Health Treatment/Services - General Classification
0901	Behavioral Health Treatment/Services - Electroshock Treatment
0914	Behavioral Health Treatment/Services - Individual Therapy
0915	Behavioral Health Treatment/Services - Group Therapy
0916	Behavioral Health Treatment/Services - Family Therapy
0918	Behavioral Health Treatment/Services - Testing

CPT/HCPCS Codes

Expand All | Collapse All

Group 1

(13 Codes)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
90785	Psytx complex interactive
90832	Psytx w pt 30 minutes
90833	Psytx w pt w e/m 30 min
90834	Psytx w pt 45 minutes
90836	Psytx w pt w e/m 45 min
90837	Psytx w pt 60 minutes
90838	Psytx w pt w e/m 60 min
90846	Family psytx w/o pt 50 min
90847	Family psytx w/pt 50 min
90849	Multiple family group psytx
90853	Group psychotherapy
90880	Hypnotherapy
90899	Unlisted psyc svc/therapy

ICD-10-CM Codes that Support Medical Necessity

N/A

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

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
012x	Hospital Inpatient (Medicare Part B only)
013x	Hospital Outpatient
085x	Critical Access Hospital

Revenue Codes

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

Providers submitting claims with bill type 12X are to report revenue code 0918 (psychiatric / psychological testing).

Code	Description
0900	Behavioral Health Treatment/Services - General Classification
0901	Behavioral Health Treatment/Services - Electroshock Treatment
0914	Behavioral Health Treatment/Services - Individual Therapy
0915	Behavioral Health Treatment/Services - Group Therapy
0916	Behavioral Health Treatment/Services - Family Therapy
0918	Behavioral Health Treatment/Services - Testing

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
01/01/2024	R3	Consistent with Change Request 13167, the following sections have been revised: Indications and Limitations, to include marriage and family therapists and mental health counselors.
01/01/2023	R2	CMS finalized a proposal to amend regulations at § 410.26(b)(5) to allow behavioral health services to be furnished under the general supervision of a physician or NPP when these services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP. The abstract article text, indications and limitations have been updated to comply with this change.
01/01/2017	R1	Administrative changes in narrative descriptions due to annual HCPCS update were made, effective for services rendered on or after January 1, 2017.

Associated Documents

Updated On	Effective Dates	Status
01/16/2024	01/01/2024 - N/A	Currently in Effect	You are here
06/29/2023	01/01/2023 - 12/31/2023	Superseded	View
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Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article

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