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.

**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expectation that if treatment services were withdrawn the patient's condition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, 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.