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

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34539-Psychological Services Coverage under
the Incident to Provision for Physicians and Non-physicians.

  ** _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. 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.  
  
If the patient receives primarily psychotherapy along with an E/M service,
and, in addition, pharmacological management at the same visit, the
psychotherapy codes, which include evaluation and management, should be used.
The pharmacological management is included as part of the E/M service by
definition, and therefore, 90863 should not be billed in addition to the
psychotherapy codes. Please refer to the CCI edits.  
  
 _**Other Guidelines:**_  
  
Psychological services are covered in Comprehensive Outpatient Rehabilitation
Facilities (CORFs). _If the CORF treatment services rendered are for both a
psychiatric condition and one or more nonpsychiatric conditions, separate the
charges for the psychiatric aspects of treatment from the charges for the
nonpsychiatric aspects. See the Medicare Claims Processing publication for
specific instructions_ (CMS Publication 100-02, _Medicare Benefit Policy
Manual_ , Chapter 12, Section 50.4).

**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.

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 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.

**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.)

In addition to ordinary standards of good clinical documentation, the legible
identity of the individual rendering the service with his/her professional
credentials must be included in the documentation of each service and
available in the medical record. Documentation of supervision by the
physician/provider billing for the "incident to" services must be present in
the medical record.  

**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 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 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 for Psychological Services Coverage under the "Incident to"
Provision for Physicians and Non-physicians services 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.)