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Local Coverage Determination (LCD)

Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians

L34539

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Proposed LCD
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34539
Original ICD-9 LCD ID
Not Applicable
LCD Title
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 04/04/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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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

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. Please see Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

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 - administered) 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.

Code of Federal Regulations:

42 CFR 410.32 states that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license) and Medicare requirements.

42 CFR 410.71 describes coverage of clinical psychologist services and supplies incident to a clinical psychologist.

42 CFR 410.73-410.76 describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
    60.1 Services and Supplies; Incident to Physician's Professional Services
    60.2 Services and supplies: 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 Manual, Chapter 1:
    70.3 Physician's Office Within an Institution - Coverage of Services and Supplies
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).
    120.1 NP and CNS "Direct Billing and Payment"
    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
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30:
    50.3 ABN Scope

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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 Pub 100-02, 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, clinical social workers, nurse practitioners, and clinical nurse specialists (CMS Pub 100-02, 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 direct physician supervision of auxiliary personnel. (CMS Pub 100-02, Chapter 15, Section 60.2). 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 Pub 100-02, Chapter 15, Section 60.2).

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 direct supervision.

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, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90880, 90899. (Codes 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, and 90828 were deleted effective 12/31/12.)

  • Doctorate or Masters level Clinical Social Worker: 90785, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90899. (Codes 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, and 90828 were deleted effective 12/31/12.)


  • Clinical Nurse Specialist (CNS): 90785, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90899 (90862, if authorized by the state to prescribe medication; this code was deleted effective 12/31/12. 90863, if authorized by the state to prescribe medication.) Note: Codes 90804-90829 and 90857 were deleted effective 12/31/12

  • Nurse Practitioner* (NP): 90785, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90846, 90847, 90849, 90853, 90857, 90899 (90862, if authorized by the state to prescribe medication; this code was deleted effective 12/31/12. 90863, if authorized by the state to prescribe medication.) Note: Codes 90804-90829 and 90857 were deleted effective 12/31/12

    *limited to advanced registered nurse practitioners with a masters degree in the mental health equivalent to a masters prepared certified clinical nurse specialist.
  • 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.)

    The practice of "marriage and family therapy" includes the identification and treatment of cognitive, affective and behavioral conditions related to marital and family dysfunctions that involve the professional application of psychotherapeutic and systems theories and techniques in the delivery of services to individuals, couples, and families. Local laws regulating their professional practice do not authorize any licensed marriage and family therapist or marriage and family therapy associate to administer or interpret psychological tests. Please refer to applicable state laws.

    Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel. (CMS Pub 100-02, Chapter 15, Section 60.2). 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 and other therapists. Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services (CMS Pub 100-02, Chapter 15, Section 60.1 - Section 60.3). 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 Pub 100-02, 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 §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 intermediary (CMS Pub 100-02, 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 directly supervised by the physician; his presence in the facility as a whole would not suffice to meet this requirement. (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 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 direct supervision. The availability of the physician by telephone or the presence of the physician somewhere in the institution does not constitute direct personal supervision (CMS Pub 100-02, Chapter 15, Section 60.1).
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
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Contractor Advisory Committee (CAC) Meetings
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MAC Meeting Information URLs
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Proposed LCD Posting Date
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Reason for Proposed LCD
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This request was MAC initiated.
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Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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 Group 1 Codes:

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

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Group 1

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information
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Sources of Information
This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators is not responsible for the continuing viability of Web site addresses listed below.

AdminaStar Federal and other Medicare contractors' Local Coverage Determinations/Local Medical Review Policies.

Medicare Part B Model Local Medical Review Policy for Psychological Services.

Respective State Web sites regarding the licensing and certification of mental health providers.
Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
04/04/2024 R10

R10

Revision Effective: 04/04/2024

Revision Explanation: Annual review, no changes were made.

03/29/2024: 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 (Annual Review)
03/02/2023 R9

R9

Revision Effective: 03/02/2023

Revision Explanation: Annual review, no changes were made.

02/24/2023: 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 (Annual Review)
03/04/2021 R8

R8

Revision Effective: 03/04/2021

Revision Explanation: Annual review, no changes were made.

02/24/2021: 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 (Annual Review)
11/28/2019 R7

R7

Revision Effective: N/A

Revision Explanation: Annual review, no changes made

02/24/2020: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 (Annual Review)
11/28/2019 R6

R6

Revision Effective: 11/28/2019

Revision Explanation: Removed the other comments from coverage and limitations section and the associated documents information in the related billing and coding article.

11/21/2019: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
09/26/2019 R5

R5

Revision Effective: 09/26/2019 Revision Explanation: Converted to new policy template that no longer includes coding section based on CR 10901.

09/20/2019: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.
  • Revisions Due To Code Removal
10/01/2015 R4

R4

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

02/27/2019: 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 (Annual Review)
10/01/2015 R3

R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

02/26/2018: 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 (Annual Review)
10/01/2015 R2 R2
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (annual review)
10/01/2015 R1 R1
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
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03/29/2024 04/04/2024 - N/A Currently in Effect You are here
02/24/2023 03/02/2023 - 04/03/2024 Superseded View
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