Billing and Coding: Psychiatry and Psychology Services

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Psychiatry and Psychology Services.

Unless otherwise indicated, these procedures may be used by providers of mental health services licensed or otherwise authorized as designated by Medicare and the state in which they practice.

National Coverage Provisions:

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 Where there is a reasonable expectation that if treatment services were withdrawn the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met (CMS Publication 100-02, Medicare Benefit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).

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).

To be covered as incident to physicians’ services, the services and supplies must be furnished by the hospital or CAH or under arrangement made by the hospital or CAH (see section 20.1.1 of this chapter). The services and supplies must be furnished as an integral, although incidental, part of the physician or nonphysician practitioner’s professional service in the course of treatment of an illness or injury. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.5.2).

The services and supplies must be furnished under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law, and furnished by hospital personnel under the supervision of a physician or nonphysician practitioner as defined at 42 CFR 410.27(f) and 482.12. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.5.2).

When the hospital makes arrangements with others for diagnostic services, such services are covered under Part B as diagnostic tests whether furnished in the hospital or in other facilities. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.4.6).

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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Specific Coding Guidelines:

Psychiatric Diagnostic Procedures 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.

Psychiatric Diagnostic Procedures 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.

The interactive complexity component code 90785 may be used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792) and psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838), and group psychotherapy (90853).

Procedure codes 90832-90838 (psychotherapy for 30 to 60 minutes) – report the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838. Procedure codes 90833, 90836 and 90838 are add on codes that should be used in conjunction with evaluation and management (E/M) codes 99201-99239, 99304-99337, 99341-99350.

Psychotherapy codes that include an evaluation and management component are payable only to physicians, PAs, NPs 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. 

90845 is not time defined, but the service is usually 45 to 50 minutes and is billed once for each daily session.

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 to support multiple families when similar dynamics are occurring due to common issues confronted in the family members under treatment.

Codes 90846 and 90847 may not be reported for services less than 26 minutes.

Codes 90846 and 90847 do not pertain to consultation and interaction with paid staff members at an institution.

90849 does not meet Medicare's standards of being a therapy primarily directed toward treating the beneficiary's condition. Claims for 90849 may be approved on an individual consideration basis.

Code 90785 is used when the patient or patients in the group setting do not have the ability to interact by ordinary verbal communication and therefore, non-verbal communication skills are employed or an interpreter may be necessary.

Use of CPT code 90865 is restricted to physicians (MD/DO) only.

"Codes 90839, 90840 are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service." (CPT 2013, Professional Edition, p.486)

When a psychiatrist performs both the ECT and the associated anesthesia, no separate payment is made for the anesthesia. Code 90870 is limited to use by physicians (MD/DO) only.

CPT codes 90875, 90876 and 90882 are not covered by Medicare.

Psychiatric procedures billed using code 90899 may be covered on an individual consideration basis.

Code 96105 represents the formal evaluation of aphasia using a psychometric instrument such as the Boston Diagnostic Aphasia Examination. This testing is typically performed once during treatment and the medical necessity for such testing should be documented. Repeat testing should only be done if there is a significant change in the patient’s aphasic condition.

"Unlisted psychiatric service or procedure" should not be used if the service is described by one of the more specified codes.
  

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

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). Providers are exempt from submitting psychotherapy notes without patient authorization when the notes in question fit the Privacy Rule definition in 45 CFR Section 164.501. This section defines psychotherapy notes as "notes recorded by a mental health professional (in any medium) which document or analyze the contents of a counseling session and that are separated from the rest of a medical record."

45 CFR Section 164.501 states that "the provider is responsible for extracting information required to perform a review for medical necessity." The provider, therefore, is expected to document information potentially necessary for review in a manner that will allow submission if this information without release of psychotherapy details that are protected by the Privacy Rule.

This following information is excluded from the protected information in 45 CFR Section 164.501, and must be included in all psychiatric medical record documentation and made available upon request:

- Name of beneficiary and date of service
- Type of service (individual, group, family, interactive, etc.)
- Time element, where duration of the face-to-face contact is the determining factor for coding the service rendered
- Modalities and frequency of treatment furnished
- A clinical note for each encounter, where in the aggregate, summarizes the following items: diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis, and progress to date. Elements such as treatment plans, functional status and prognostic assessment are expected to be documented, updated and available for review, but do not need to be delineated for each individual date of service.
- Identity and professional credentials of the person performing service

For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these non-verbal interactive techniques

For psychotherapy services that include a medical evaluation and management component, documentation of the medical evaluation or management component of the treatment, including prescriptions, monitoring of medication effects, co-morbid medical conditions evaluated, and results of clinical tests.

Group therapy session notes must be prepared within a reasonable time period after the rendering of professional services consistent with accepted practice, and can be organized according to the general session note guidelines for individual therapy or the clinician may elect to use the following group note format:

• One portion of the note that is common to all patients, documenting date, length of time for the session, along with key issues presented. Names of the patients in the group should not appear in this group note.

• A second portion of the note, for each patient's record, commenting on that particular patient's participation in the group process and any significant changes in patient status. As outlined in HIPAA regulations referenced above, the note should exclude sensitive content of the patients' conversation.

While there are no specific limitations on the frequency or length of time that outpatient psychiatric services may be covered, there are many factors, including the nature of the illness, prior history, goals of treatment, and the patient’s response, that affect the outcome of treatment. When outpatient psychiatric services are provided at a high frequency or long duration, the plan of treatment, progress notes, and condition of the patient should justify the intensity of the services rendered.

For psychotherapy services, there should be documentation of the patient's capacity to participate in and benefit from psychotherapy, especially if the patient is in any way cognitively impaired. The medical record should document the target symptoms, goals of therapy and methods of monitoring outcome. There should be documentation in the medical record of how the treatment is expected to improve the health status or function of the patient.

Those hospitals that provide services at off-campus locations must clearly document in the medical record the location of the billed services, and that the services were properly supervised.

The medical record must reflect the elements outlined in the Psychiatric Diagnostic Procedures description and must be rendered by a qualified provider (see "Limitations" in related LCD).

The medical record must reflect the elements outlined in the above Interactive Complexity description and must be rendered by a qualified provider (see "Limitations" subsection in related LCD). Additionally, the medical record must include adaptations utilized in the session and the rationale for employing these interactive techniques. The medical record must include treatment recommendations.

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.

The medical record must document the indications for psychoanalysis, description of the transference, and the psychoanalytic techniques used.

The medical record must document the conditions described under the psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy "Description" and "Comments" sections in related LCD relative to codes 90846, 90847, and 90849.

The medical record should document the medical necessity of narcosynthesis for psychiatric diagnostic and/or therapeutic purposes (e.g., the patient had difficulty verbalizing their 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.

The record must indicate that the Psychotherapy in Crisis guidelines under the "Description" and "Comments" sections in the related LCD were followed.

Claims for 90880 must be submitted with a covered diagnosis.

The medical record must indicate the presence of mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.

The medical record must document that the Central Nervous System Assessments/Tests guidelines outlined in the "Description" and "Comments" sections in the related LCD were followed.