Billing and Coding: Outpatient Psychiatry and Psychology Services

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34353 Outpatient Psychiatry and Psychology
Services.



**General Guidelines for Claims submitted to Part A or Part B MAC:**

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.

**General Coding Guidelines for Psychiatry and Psychology Services:  
  
** 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.  
  
Under certain circumstances, facilities may component bill the services of
physicians, clinical psychologists, clinical social workers, and clinical
nurse specialists and submit the facility fee services to the Part A MAC with
the appropriate revenue and HCPCS codes. Hospitals should be advised that
facility fee charges submitted to the Part A MAC must meet the same medical
necessity and documentation standards as described elsewhere in the Local
Coverage Determination for Psychiatry and Psychology Services.  
  
Individual psychotherapy codes should be used only when the focus of the
treatment encounter involves psychotherapy. Psychotherapy codes should not be
used as generic psychiatric service codes when another code, such as an E/M or
pharmacological management code, would be more appropriate.  
  
If the patient receives primarily psychotherapy and, in addition,
pharmacological management at the same visit, the psychotherapy codes, which
include evaluation and management, should be used in addition to 90863 for the
pharmacological management can be be billed. Please refer to the National
Correct Coding Initiative (NCCI) edits.  
  
CPT code 90863 is not intended to be used for the actual administration of
medication, nor is it intended to be used for observation of the patient
taking an oral medication. Administration and supply of oral medication is not
a separately payable service.

**Other Guidelines:  
  
** Activity therapy and education and training are not separately paid under
OPPS. Activity therapy services are limited to services provided as a
component of a PHP. Non-partial hospitalization bills submitted with revenue
code 0904 for activity therapy will be returned to the provider. Patient
education and training services are packaged into the overall costs associated
with outpatient psychiatric services and are not a separately paid service;
however, reporting is necessary for the purpose of data analysis. Hospitals
may report patient education and training services for psychiatric purposes
with revenue code 0942. (CMS Program Memorandum, Transmittal A-01-111, Change
Request #1798, September 14, 2001, clarifies activity therapy and patient
education and training under the Hospital Outpatient Prospective Payment
System [OPPS].)

**Advance Beneficiary Notice of Non-coverage (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.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**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 Outpatient Psychiatry and Psychology Services are payable under
Medicare Part B in the following places of service: school (3), homeless
shelter (4), office (11), home (12), assisted living facility (13), group home
(14), temporary lodging (16), urgent care facility (20), in-hospital (21),
outpatient hospital (22), hospital emergency room (23), skilled nursing home
for patients in a Part A stay (31), nursing facility for patients not in a
Part A stay (32), adult home (33), independent clinic (49), inpatient
psychiatric facility (51), psychiatric facility partial hospitalization (52),
community mental health center (53), intermediate care facility/mentally
retarded (54), residential substance abuse treatment center (55), psychiatric
residential treatment center (56), non-residential substance abuse treatment
center (57), comprehensive inpatient rehabilitation facility (61),
comprehensive outpatient rehabilitation facility (62), state or local public
health clinic (71) and adult daycare (99).  
  
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-10-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-10-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._

****Documentation Requirements****

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

  
The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this 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  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 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.

**Other Comments:  
  
** For claims submitted to the Part A MAC: this coverage determination also
applies within states outside the primary geographic jurisdiction with
facilities that have nominated CGS Administrators, LLC to process their
claims.  
  
Bill type codes only apply to providers who bill these services to the Part A
MAC. Bill type codes do not apply to physicians, other professionals and
suppliers who bill these services to the carrier or Part B MAC.  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.  
  
For outpatient settings other than CORFs, references to "physicians"
throughout this policy include non-physicians, such as nurse practitioners,
clinical nurse specialists and physician assistants. Such non-physician
practitioners, with certain exceptions, may certify, order and establish the
plan of care as authorized by State law. (See Sections 1861[s][2] and
1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections
410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)  
  
General Comments Regarding Coverage of Outpatient Hospital Diagnostic and
Therapeutic Services:  
  
Therapeutic services defined as hospital services and provided by a hospital
on an outpatient basis are incident to the services of physicians in the
treatment of patients. _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's professional services in the course or
treatment of an illness or injury_ (CMS Publication 100-02, _Medicare Benefit
Policy Manual_ , Chapter 6, Section 20.5.1).  
  
 _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, furnished_ by hospital personnel and under
_the direct supervision of a physician or clinical psychologist as defined in
42 CFR 410.32(b)(3)(ii) and 482.12._ (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 6, Section 20.5.1).  
  
 _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 20.4.5).