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

**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, clinical social workers, 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.  
  
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.

  1. Doctorate or Masters level Clinical Psychologist: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90880, 90899
  2. Doctorate or Masters level Clinical Social Worker: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
  3. Clinical Nurse Specialist (CNS): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
  4. Nurse Practitioner (NP): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899
  5. Other providers of mental health services licensed or otherwise authorized by the state in which they practice for services within their scope of practice (e.g., licensed clinical professional counselors, licensed marriage and family therapists). These other providers may not bill Medicare directly for their services, but may provide mental health treatment services to Medicare beneficiaries under the "incident to" provision.

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
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 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