Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Medicare Carriers Policies 
for Mental Health Services 
JANET REHNQUIST 
INSPECTOR GENERAL 
MAY 2002 
OEI-03-99-00132  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To review coverage criteria and documentation requirements set forth in Medicare carriers local 
medical review policies for selected Part B mental health services. 
BACKGROUND 
Medicare and its beneficiaries paid an estimated $1.2 billion for Part B mental health services in 
1998.  Part B claims for mental health services are processed and paid by Medicare carriers 
that contract with the Centers for Medicare & Medicaid Services (CMS). To date, CMS has 
not established a national coverage policy for all carriers to follow in assessing the 
appropriateness of claims for mental health services.  Rather, carriers are permitted to develop 
local medical review policies in accordance with a format published by CMS. These policies 
describe the medical criteria beneficiaries must meet for particular mental health services to be 
considered medically necessary and appropriate, as well as criteria for satisfactory 
documentation of mental health services. 
For this inspection, we collected local medical review policies from Medicare Part B carriers for 
the following mental health services: individual psychotherapy with and without evaluation and 
management, group psychotherapy, pharmacologic management, and psychological testing.  We 
systematically reviewed these local policies using a structured review instrument. 
FINDINGS 
Some carriers did not have local medical review policies for the mental health 
services in our review 
A total of nine carriers lacked policies for one or more of the mental health services we 
reviewed. One carrier did not have a local medical review policy for any type of mental health 
service. Three carriers did not have policies addressing group psychotherapy. Another two 
carriers did not have policies for pharmacologic management. An additional three carriers did 
not have local medical review policies for psychological testing. 
Not all carriers provided comprehensive and specific coverage criteria in their local 
policies for mental health services 
The comprehensiveness and specificity with which carriers addressed the coverage criteria 
outlined in the local medical review policy format varied from one carriers policy to the next. 
i 
Carriers Policies for Mental Health Services  OEI-03-99-00132  Variations also existed within individual policies, with explicit coverage requirements for one type 
of mental health service, yet vague requirements for another.  Few policies provided utilization 
guidelines for group therapy, pharmacologic management, and psychological testing. In addition, 
few policies indicated covered diagnoses for psychotherapy and psychological testing services. 
While most policies for group therapy and pharmacologic management specified qualified 
providers, policies for individual therapy and psychological testing did not. 
Documentation requirements for therapy and pharmacologic management were 
also not comprehensive and consistent 
According to CMS local medical review policy format, carriers policies must establish 
requirements for the documentation of services.  Our review revealed that documentation 
requirements set forth for individual and group psychotherapy and pharmacologic management 
were not comprehensively and consistently addressed in carriers policies. In contrast, the 
majority of carriers policies for psychological testing outlined specific documentation that should 
be included in the patients medical record. 
RECOMMENDATION 
We believe that all Medicare beneficiaries should have access to medically appropriate mental 
health services, and that providers should adequately document these services. We also believe 
that the quality and comprehensiveness of guidance furnished to mental health service providers 
should not vary depending on which carrier is processing payment for services. The lack of 
comprehensive guidance in local medical review policies may result in inconsistent Medicare 
coverage determinations and inappropriate payments for mental health services.  Therefore, 
<	 We recommend that CMS require carriers to strengthen vague or incomplete 
sections of their local policies for mental health services and ensure that policies 
adequately address all of the elements specified in the Local Medical Review 
Policy Format (Medicare Program Integrity Manual, Exhibit 6). 
Comprehensive and detailed policies for mental health services might include: 
<	 specific documentation instructions requiring that basic elements such as date of 
service, diagnosis, symptoms, progress, and name and credentials of 
practitioners rendering services be recorded in patients medical records; 
<  specific utilization guidelines such as those pertaining to a reasonable number of 
services that may be billed per year; and 
<  sample progress notes for specific types of mental health services. 
For additional assistance in targeting areas for inclusion in comprehensive policies, we have 
provided tables in Appendix A outlining the information Medicare carriers included in their local 
medical review policies. 
ii 
Carriers Policies for Mental Health Services  OEI-03-99-00132  COMMENTS 
We received comments on the draft report from the Centers for Medicare & Medicaid Services 
and from two professional organizations, the American Association for Geriatric Psychiatry and 
the American Psychiatric Association. The full text of the comments is presented in Appendix E. 
CMS Comments 
The CMS concurred with our recommendation and noted that, over the last several years, it has 
instructed Medicare contractors to develop their local medical review policies in an open forum 
and to periodically review these policies to ensure consistency with national Medicare policy and 
changes in payment and operating systems. The CMS stated that it will require that contractors 
periodic reviews of local medical review policies include strengthening vague or incomplete 
sections of these policies for all services. In addition, CMS will share our report with Medicare 
carriers and instruct them to make sure that their local policies reflect Medicare Program 
Integrity Manual requirements. 
Comments of Mental Health Organizations 
Both the American Association for Geriatric Psychiatry and the American Psychiatric 
Association remarked on the need for national standards for coverage and payment of mental 
health services that all Medicare carriers must follow. Consideration of the adoption of national 
standards was outside the scope of our review. However, the organizations views about the 
need for a national policy are attached and available for consideration by CMS. 
The organizations expressed concern about our suggestion that carriers might want to include 
specific utilization guidelines for mental health services in their local policies. They believe that 
these types of guidelines may pose a threat to the sickest patients who need more frequent and 
intensive treatment if carriers presume that services beyond the guidelines are medically 
unnecessary. We agree that any utilization guidelines presented in carriers policies should not 
be used to impede access to appropriate mental health services. 
In addition, the American Psychiatric Association inquired about the source of the descriptions 
of the mental health service codes provided in Appendix B. We have revised Appendix B to 
reflect the code descriptions in the American Medical Associations Current Procedural 
Terminology. 
iii 
Carriers Policies for Mental Health Services  OEI-03-99-00132  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ....................................................... i

INTRODUCTION ............................................................. 1

FINDINGS 
Some Carriers Lacked Policies for the Mental Health Services Reviewed  ............... 4

Not All Carriers Provided Comprehensive and Specific Coverage Criteria  .............. 4

Documentation Requirements Weak for Therapy and Pharmacologic Management  ........ 6

RECOMMENDATION  ........................................................ 8

APPENDICES

A: Selected LMRP Review Results by Carrier Number............................ 10

B: Descriptions of Mental Health Services Reviewed.............................. 15

C: Local Medical Review Policy Format ....................................... 16

D: Selected OIG Reports on Medicare Mental Health Services ...................... 24

E: Comments on the Draft Report ............................................ 26

ACKNOWLEDGMENTS ..................................................... 37

iv 
Carriers Policies for Mental Health Services  OEI-03-99-00132  I N T R O D U C T I O N  
PURPOSE 
To review coverage criteria and documentation requirements set forth in Medicare carriers local 
medical review policies for the following Part B mental health services: individual psychotherapy 
with and without evaluation and management, group psychotherapy, pharmacologic 
management, and psychological testing. 
BACKGROUND 
Mental Illness and Medicare Populations 
As defined by the Office of the Surgeon General, mental illness is a term that refers collectively 
to all mental disorders. Mental disorders are health conditions that are characterized by 
alterations in thinking, mood, or behavior (or some combination thereof) associated with distress 
and/or impaired functioning.  People of all age groups can be affected by mental illness; and 
individuals in different stages of life may be susceptible to certain kinds of mental disorders. 
Older adults have their own special mental health problems and needs. Fortunately, treatment 
interventions such as psychotherapy and medication can benefit individuals with mental illness 
when tailored to meet the specific needs of each patient. 
Medicare Part B Coverage of Mental Health Services 
Medicare and its beneficiaries paid an estimated $1.2 billion for Part B mental health services in 
1998. Mental health services reimbursed by Medicare include psychiatric diagnostic or 
evaluative interview procedures, individual psychotherapy, group psychotherapy, family 
psychotherapy, psychoanalysis, psychological testing, and pharmacologic management.  Section 
1862 (a)(1)(A) of the Social Security Act states that all Medicare Part B services, including 
mental health services, must be reasonable and necessary for the diagnosis or treatment of an 
illness or injury or to improve the functioning of a malformed body member. 
Medicare Carriers and Local Medical Review Policies 
Part B claims for mental health services are processed and paid by health insurance 
organizations, known as Medicare carriers, that contract with the Centers for Medicare & 
Medicaid Services (CMS).  Carriers are identified by one or more unique numbers that 
correspond to the jurisdiction(s), usually States or portions of States, for which they process 
Medicare claims.  Some carrier organizations have more than one area of jurisdiction, and some 
States have more than one Medicare carrier. 
1 
Carriers Policies for Mental Health Services  OEI-03-99-00132  To date, CMS has not established a national coverage policy for all carriers to follow in 
assessing the appropriateness of claims for mental health services. The CMS allows, but does 
not require, carriers to develop their own local medical review policies based on general 
Medicare guidelines.  Local policies for mental health services should describe the medical 
criteria beneficiaries must meet for particular services to be considered medically necessary and 
appropriate.  Exhibit 6 of the Medicare Program Integrity Manual indicates a general format that 
carriers must use when writing their local policies.  The most current format is presented in 
Appendix C.  Local policies provide information about coverage, including appropriate 
diagnosis and utilization guidelines; documentation requirements; and coding and billing of 
services. 
Documentation of Mental Health Services 
Section 1833 (e) of the Social Security Act requires providers to maintain sufficient 
documentation of the services they render to Medicare beneficiaries in order to support claims 
for reimbursement. When carriers have local policies in place, these policies should specify 
criteria for satisfactory documentation of mental health services.  Record-keeping guidelines 
published by the American Psychological Association state that well-documented mental health 
services are critical to patient care.  Thorough documentation ensures continuity of care should a 
patient seek treatment from another health care provider for either mental or physical conditions; 
enables mental health professionals to better plan for and monitor treatment; and substantiates 
mental health claims submitted to the Medicare program and other insurers. 
Previous OIG Work 
Since 1996 the Office of Inspector General (OIG) has issued a number of reports on mental 
health services provided to Medicare beneficiaries in nursing facilities, hospital outpatient 
departments, partial hospitalization programs, and other outpatient settings.  The OIG found that 
many mental health services provided to beneficiaries in these settings were medically 
unnecessary, highly questionable, billed incorrectly, and undocumented or poorly documented. 
In a January 2001 report on psychiatric services in nursing homes, the OIG found that Medicare 
carriers local medical review policies addressed psychiatric services in nursing homes, but that 
utilization guidelines were inconsistent and unclear.  An OIG report issued in May 2001 revealed 
that Medicare allowed $185 million in 1998 for inappropriate mental health services provided in 
practitioners offices, community mental health centers, beneficiaries homes, and custodial care 
facilities.  A listing of selected OIG reports on Medicare mental health services is provided in 
Appendix D. 
2 
Carriers Policies for Mental Health Services  OEI-03-99-00132  METHODOLOGY 
We requested 1998 local policies from each of the Medicare Part B carriers for the following 
mental health services: individual psychotherapy with and without evaluation and management, 
group psychotherapy, pharmacologic management, and psychological testing. Descriptions of 
these services are provided in Appendix B. 
We did not receive responses to our request from carriers representing 3 of 57 unique carrier 
numbers. One carrier responded to our request, but stated that they did not have a local policy 
in place for the mental health services in our review. The remaining carriers, representing 53 
unique carrier numbers, submitted either a single policy covering all of the Part B mental health 
services under review, or separate policies for each type of mental health service.  We created a 
structured review instrument and systematically reviewed the local policies, focusing on coverage 
criteria and documentation requirements. We focused our review on these elements as they 
make up the essence of local medical review policies. 
We recorded the results of our analysis of local policies in terms of unique carrier numbers. 
However, to improve the readability of this report, we will refer to these unique carrier numbers 
as carriers.  Detailed tables containing all of the analysis results presented in this report are 
provided in Appendix A. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
3 
Carriers Policies for Mental Health Services  OEI-03-99-00132  F I N D I N G S  
Some carriers did not have local medical review policies for 
the mental health services in our review 
A total of nine carriers lacked policies for one or more of the mental health services we 
reviewed. One carrier did not have a local medical review policy for any type of mental health 
service. Three carriers did not have policies addressing group psychotherapy. Another two 
carriers did not have policies for pharmacologic management. An additional three carriers did 
not have local medical review policies for psychological testing. 
Table 1. Nine Carriers Lacked Policies For One Or More Mental Health Services 
Medicare Part B Carrier  Mental Health Services Reviewed 
(X indicates that carrier had policy covering the service) 
Individual  Group  Pharmacologic  Psychological 
Number  Name  State  Therapy  Therapy  Management  Testing 
00870  Rhode Island Blue Shield  RI 
00650  Kansas Blue Shield  KS  X  X  X 
00651  Kansas Blue Shield  MO  X  X  X 
00655  Kansas Blue Shield  NE  X  X  X 
00590  Florida Blue Shield  FL  X  X  X 
00880  Palmetto GBA  SC  X  X  X 
16360  Nationwide  OH  X  X  X 
16510  Nationwide  WV  X  X  X 
31140  National Heritage Insurance Co.  CA  X  X  X 
Source: OEI analysis of 1998 local medical review policies collected between September and December 1999. 
Not all carriers provided comprehensive and specific 
coverage criteria in their local policies for mental health 
services 
The comprehensiveness and specificity with which carriers addressed coverage criteria for the 
mental health services we reviewed varied from one carriers local medical review policy to the 
next. Variations also existed within individual policies, with explicit coverage requirements for 
one type of mental health service, yet vague requirements for another. 
4 
Carriers Policies for Mental Health Services  OEI-03-99-00132  Few policies provided utilization guidelines for group therapy, pharmacologic 
management, and psychological testing 
The CMS local medical review policy format (provided in Appendix C) suggests that carriers 
policies describe the typical usage of covered services. However, few policies delineated 
utilization guidelines for group psychotherapy, pharmacologic management, and psychological 
testing services.  Four policies stated the number of group psychotherapy services that may be 
billed per year. Three policies stated the number of pharmacologic management services that 
may be billed per year. Nine policies specified the number of hours that may be billed per 
beneficiary per psychological testing service, while five policies specified the number of 
psychological testing services that may be provided in a 12-month period. 
In contrast, the majority (about two-thirds) of local policies we reviewed provided utilization 
guidelines for individual psychotherapy services. These policies specified that prolonged 
treatment with individual psychotherapy may be subject to medical review, with most policies 
defining prolonged treatment as treatment in excess of 20 sessions per episode of illness. One 
individual psychotherapy policy provided greater detail, basing utilization guidelines on additional 
criteria such as place of service (inpatient or outpatient) and whether a patients illness is chronic 
or acute. 
Few policies clearly indicated covered diagnoses for psychotherapy and 
psychological testing services 
The local medical review policy format published by CMS states that policies must contain a list 
of diagnosis codes for which a service is generally covered.  Although local medical review 
policies for mental health services usually contained a general list of covered diagnosis codes, 
only eight policies clearly indicated which diagnoses are associated with each type of mental 
health service we reviewed.  However, the typical policy governing pharmacologic management 
did specify a range of diagnosis codes that are covered for pharmacologic management services. 
Most policies for group therapy and pharmacologic management specified 
qualified providers, unlike individual therapy and psychological testing policies 
While the local medical review policy format does not explicitly state that carriers policies must 
list the types of providers qualified to render services, many local policies specified the types of 
providers that are permitted to render group psychotherapy and pharmacologic management 
services.  These policies generally stated that group psychotherapy must be led by a person 
authorized by the state to perform this service, but also provided a list of practitioner types that 
are usually qualified to perform group therapy, including psychiatrists, psychologists, clinical 
social workers, nurse practitioners, and clinical nurse specialists. Most policies specified that 
pharmacologic management is a physician service, with exceptions for other types of 
practitioners that may be licensed by individual States to prescribe medication, such as nurse 
practitioners, advanced practice nurses, and physician assistants. 
5 
Carriers Policies for Mental Health Services  OEI-03-99-00132  In contrast to group therapy and pharmacologic management services, local medical review 
policies usually did not identify the specific types of providers that are permitted to render 
individual psychotherapy and psychological testing services. Typical policies for individual 
psychotherapy merely stated that the service must be performed by a person authorized by the 
state to perform psychotherapy. Only one-quarter of policies stipulated that clinical 
psychologists and licensed clinical social workers are not qualified to render individual 
psychotherapy with an evaluation and management component, a service clearly outside the 
scope of practice for these practitioners. For psychological testing, nine policies specified the 
types of providers that may render these services. 
Documentation requirements for therapy and pharmacologic 
management were also not comprehensive and consistent 
Our review revealed that documentation requirements set forth for individual and group 
psychotherapy and pharmacologic management were not comprehensively and consistently 
addressed in carriers policies.  In contrast, the majority of carriers policies for psychological 
testing outlined specific documentation that should be included in the patients medical record. 
According to CMS local medical review policy format, carriers policies must establish 
requirements for the documentation of services. Documentation should include specific 
information from the medical records or other pertinent information that would be required to 
justify the item/service. 
Individual and Group Psychotherapy. Many local medical review policies did not address 
the documentation of some very basic elements of psychotherapy services. Less than half of 
policies for individual and group psychotherapy specified that a patients diagnosis should be 
documented in the medical record. Very few carriers stipulated that the date of an individual or 
group psychotherapy session should be recorded in patients medical records. Just over half of 
policies for individual psychotherapy required documentation that treatment is expected to 
stabilize patients with chronic illness. 
Forty-two percent of policies for group psychotherapy contained a similar requirement. 
However, local medical review policies for individual and group psychotherapy services did 
provide consistent documentation requirements with respect to other important elements. For 
example, almost all policies for both individual and group psychotherapy required documentation 
of the goals of therapy and the estimated duration of treatment.  As individual psychotherapy is 
billed in increments of time, most local medical review policies for this service stipulated that the 
amount of face-to-face time spent with the patient in an individual therapy session should be 
documented. 
6 
Carriers Policies for Mental Health Services  OEI-03-99-00132  Pharmacologic Management. Most policies for pharmacologic management either did not 
address documentation of pharmacologic management services at all, or did so using very vague 
language. Of the 53 carrier policies reviewed, only 9 policies contained explicit standards for 
the documentation of pharmacologic management services.  Two of these policies provided a 
detailed list of elements that should be documented for this service, including the patients 
diagnosis, pertinent signs and symptoms, the medication prescribed, side effects, related 
monitoring of laboratory tests if appropriate, responses to treatment, and any orders for changes 
in the regimen. Another policy provided examples of progress notes that contain appropriate 
documentation of pharmacologic management services. 
Psychological Testing. Overall, most local medical review policies for psychological testing 
services provided detailed documentation requirements. For example, over 
three-quarters of policies stated that a patients medical record must indicate the presence or 
signs of mental illness that necessitate psychological testing, the specific psychological tests 
performed, and the psychological test results and/or test scores. Most policies also required 
psychological testing providers to prepare a report interpreting a patients test results.  In 
addition, the majority of carriers policies required documentation of the time involved in 
administering, scoring, interpreting, and reporting psychological test results. 
7 
Carriers Policies for Mental Health Services  OEI-03-99-00132  R E C O M M E N D A T I O N  
We believe that all Medicare beneficiaries should have access to medically appropriate mental 
health services, and that providers should adequately document these services. We also believe 
that the quality and comprehensiveness of guidance furnished to mental health service providers 
should not vary depending on which carrier is processing payment for services. The lack of 
comprehensive guidance in local medical review policies may result in inconsistent Medicare 
coverage determinations and inappropriate payments for mental health services.  Therefore, 
<	 We recommend that CMS require carriers to strengthen vague or incomplete 
sections of their local policies for mental health services and ensure that policies 
adequately address all of the elements specified in the Local Medical Review 
Policy Format (Medicare Program Integrity Manual, Exhibit 6). 
Comprehensive and detailed policies for mental health services might include: 
<	 specific documentation instructions requiring that basic elements such as date of 
service, diagnosis, symptoms, progress, and name and credentials of 
practitioners rendering services be recorded in patients medical records; 
<  specific utilization guidelines such as those pertaining to a reasonable number of 
services that may be billed per year; and 
<  sample progress notes for specific types of mental health services. 
For additional assistance in targeting areas for inclusion in comprehensive policies, we have 
provided tables in Appendix A outlining the information Medicare carriers included in their local 
medical review policies. 
COMMENTS 
We received comments on the draft report from the Centers for Medicare & Medicaid Services 
and from two professional organizations, the American Association for Geriatric Psychiatry and 
the American Psychiatric Association. The full text of the comments is presented in Appendix E. 
CMS Comments 
The CMS concurred with our recommendation and noted that, over the last several years, it has 
instructed Medicare contractors to develop their local medical review policies in an open forum 
and to periodically review these policies to ensure consistency with national Medicare policy and 
changes in payment and operating systems. The CMS stated that it will require that contractors 
8 
Carriers Policies for Mental Health Services  OEI-03-99-00132  periodic reviews of local medical review policies include strengthening vague or incomplete 
sections of these policies for all services. In addition, CMS will share our report with Medicare 
carriers and instruct them to make sure that their local policies reflect Medicare Program 
Integrity Manual requirements. 
Comments of Mental Health Organizations 
Both the American Association for Geriatric Psychiatry and the American Psychiatric 
Association remarked on the need for national standards for coverage and payment of mental 
health services that all Medicare carriers must follow. Consideration of the adoption of national 
standards was outside the scope of our review. However, the organizations views about the 
need for a national policy are attached and available for consideration by CMS. 
The organizations expressed concern about our suggestion that carriers might want to include 
specific utilization guidelines for mental health services in their local policies. They believe that 
these types of guidelines may pose a threat to the sickest patients who need more frequent and 
intensive treatment if carriers presume that services beyond the guidelines are medically 
unnecessary. We agree that any utilization guidelines presented in carriers policies should not 
be used to impede access to appropriate mental health services. 
In addition, the American Psychiatric Association inquired about the source of the descriptions 
of the mental health service codes provided in Appendix B. We have revised Appendix B to 
reflect the code descriptions in the American Medical Associations Current Procedural 
Terminology. 
9 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  A 
Selected LMRP Review Results by Carrier Number

Appendix A contains four tables, one for each of the following types of mental health services 
included in our inspection: individual psychotherapy with and without evaluation and 
management, group psychotherapy, pharmacologic management, and psychological testing. 
These tables display selected results of our analysis of carriers local medical review policies, as 
discussed in the findings of this report.  We collected local medical review policies for the year 
1998 from the Medicare Part B carriers between September and December 1999. 
10 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XA   
T A B L E  1:  I N D I V I D U A L  P S Y C H O T H E R A P Y 
Carrier  Utilization  Diagnosis  Qualified Providers  Documentation Requirements 
Prolonged  How LMRP  How LMRP  Certain Provider Types  Estimated  Therapy Will  Date 
Guidelines  Treatment = More  Specified Covered  Specified Qualified  Cannot Bill Evaluation  Therapy  Time  Duration of  Stabilize  Patient  of 
Number  State  Provided  Than 20 Sessions  Diagnoses  Provider Types  and Management Codes  Goals  Spent  Treatment  Chronic Illness  Diagnosis  Session 
00510  AL  X  X  G  A  X  X  X 
00511  GA  X  X  G  A  X  X  X 
00520  AR  X  X  G  A  X  X  X  X 
00521  NM  X  X  G  A  X  X  X  X  X 
00522  OK  X  X  G  A  X  X  X  X  X 
00523  MO  X  X  G  A  X  X  X  X 
00528  LA  X  X  G  A  X  X  X  X  X  X 
00590  FL  S  L  X  X  X  X  X 
00630  IN  S  A  X  X  X  X 
00650  KS  S  X  X  X 
00651  MO  S  X  X  X 
00655  NE  S  X  X  X 
00660  KY  S  A  X  X  X  X 
00751  MT  X  G  A  X  X  X  X 
00801  NY  G  L  X  X  X 
00803  NY  G  L  X  X  X 
00820  ND  X  X  G  A  X  X  X 
00824  CO  X  X  G  A  X  X  X 
00825  WY  X  X  G  A  X  X  X 
00826  IA  X  X  G  A  X  X  X 
00831  AK  X  X  G  A  X  X  X 
00832  AZ  X  X  G  A  X  X  X 
00834  NV  X  X  G  A  X  X  X 
00835  OR  X  X  G  A  X  X  X 
00836  WA  X  X  G  A  X  X  X 
00860  NJ  X  X  S  A  X  X  X  X  X 
00865  PA  X  X  S  A  X  X  X  X  X 
00870  RI  NP  NP  NP  NP  NP  NP  NP  NP  NP  NP  NP 
00880  SC  S  L  X  X  X  X 
00889  SD  X  X  G  A  X  X  X 
00900  TX  A  X  X  X  X 
00901  MD  A  X  X  X  X 
00902  DE  X  X  S  A  X  X  X  X  X 
00903  DC  X  X  S  A  X  X  X  X  X 
00910  UT  S  A  X  X  X 
00951  WI  X  G  A  X  X  X  X  X  X 
00952  IL  X  X  G  A  X  X  X 
00953  MI  X  X  G  A  X  X  X 
02050  CA  X  S  A  X  X 
05130  ID  X  X  G  A  X  X  X  X 
05440  TN  X  X  G  A  X  X  X  X  X 
05535  NC  X  X  G  A  X  X  X  X 
10230  CT  S  L  X  X 
10240  MN  X  X  A  X  X  X  X 
10250  MS  X  X  A  X  X  X  X 
10490  VA  X  S  A  X  X  X  X  X 
14330  NY  G  L  X  X  X 
16360  OH  S  A  X  X  X  X  X  X  X 
16510  WV  S  A  X  X  X  X  X  X  X 
31140  CA  S  X  X  X  X  X 
31142  ME  X  X  X  X  X  X 
31143  MA  X  X  X  X  X  X 
31144  NH  X  X  X  X  X  X 
31145  VT  X  X  X  X  X  X 
KEY:	 X=Policy contained column criteria; Shaded Box=Policy did not contain column criteria; NP=No policy; G=Policy specified 
covered diagnoses in general way; S=Policy specified covered diagnosis in clear and specific way; A=Qualified provider types 
not listed, policy only specified that providers must be authorized by State; L=Policy listed qualified provider types 
11 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XA   
T A B L E  2:  G R O U P  P S Y C H O T H E R A P Y 
Carrier  Utilization  Diagnosis  Qualified Providers  Documentation Requirements 
Specified Number of  How LMRP  Specific List of  Estimated  Therapy Will  Date 
Services That May  Specified Covered  Qualified  Therapy  Duration of  Patient  Stabilize  of 
Number  State  Be Billed Per Year  Diagnoses  Provider Types  Goals  Treatment  Diagnosis  Chronic Illness  Session 
00510  AL  G  X  X  X 
00511  GA  G  X  X  X 
00520  AR  G  X  X  X  X 
00521  NM  G  X  X  X  X  X 
00522  OK  G  X  X  X  X  X 
00523  MO  G  X  X  X  X 
00528  LA  G  X  X  X  X  X 
00590  FL  S  X  X  X  X 
00630  IN  S  X  X  X  X 
00650  KS  NP  NP  NP  NP  NP  NP  NP  NP 
00651  MO  NP  NP  NP  NP  NP  NP  NP  NP 
00655  NE  NP  NP  NP  NP  NP  NP  NP  NP 
00660  KY  S  X  X  X  X 
00751  MT  G  X  X  X  X 
00801  NY  G  X  X 
00803  NY  G  X  X 
00820  ND  G  X  X  X 
00824  CO  G  X  X  X 
00825  WY  G  X  X  X 
00826  IA  G  X  X  X 
00831  AK  G  X  X  X 
00832  AZ  G  X  X  X 
00834  NV  G  X  X  X 
00835  OR  G  X  X  X 
00836  WA  G  X  X  X 
00860  NJ  S  X  X  X  X  X 
00865  PA  S  X  X  X  X  X 
00870  RI  NP  NP  NP  NP  NP  NP  NP  NP 
00880  SC  S  X  X  X  X 
00889  SD  G  X  X  X 
00900  TX  X  X  X  X 
00901  MD  X  X  X  X 
00902  DE  S  X  X  X  X  X 
00903  DC  S  X  X  X  X  X 
00910  UT  S  X  X  X 
00951  WI  G  X  X  X  X  X 
00952  IL  G  X  X  X 
00953  MI  G  X  X  X 
02050  CA  S  X  X 
05130  ID  G  X  X  X 
05440  TN  G  X  X  X  X  X 
05535  NC  G  X  X  X  X 
10230  CT  S  X  X  X 
10240  MN  X  X  X  X 
10250  MS  X  X  X  X 
10490  VA  S  X  X  X  X  X 
14330  NY  G  X  X 
16360  OH  S  X  X  X  X  X 
16510  WV  S  X  X  X  X  X 
31140  CA  S  X  X 
31142  ME  X  X  X  X 
31143  MA  X  X  X  X 
31144  NH  X  X  X  X 
31145  VT  X  X  X  X 
KEY:	 X=Policy contained column criteria; Shaded Box=Policy did not contain column criteria; NP=No policy; G=Policy specified 
covered diagnoses in general way; S=Policy specified covered diagnosis in clear and specific way 
12 
Carriers Policies for Mental Health Services  OEI-03-99-00132  T A B L E   3:   P H A R M A C O L O G I C   M A N A G E M E N T
Carrier Utilization Diagnosis Qualified Providers Documentation Requirements
Specified Number of How LMRP  How LMRP Addressed Provided Explicit
Services That May Specified Covered Specified Qualified Documentation Using Documentation
Number State Be Billed Per Year Diagnoses Provider Types Vague Language Guidelines
00510 AL S PO X
00511 GA S PO X
00520 AR S PO X
00521 NM S PO X
00522 OK S PO X
00523 MO S P X
00528 LA S PO X
00590 FL NP NP NP NP NP
00630 IN S PO
00650 KS X S X
00651 MO X S X
00655 NE X S X
00660 KY S PO
00751 MT G PO X
00801 NY S PO X
00803 NY S PO X
00820 ND S PO X
00824 CO S PO X
00825 WY S PO X
00826 IA S PO X
00831 AK S PO X
00832 AZ S PO X
00834 NV S PO X
00835 OR S PO X
00836 WA S PO X
00860 NJ S PO X
00865 PA S PO X
00870 RI NP NP NP NP NP
00880 SC NP NP NP NP NP
00889 SD S PO X
00900 TX S PO X
00901 MD S PO X
00902 DE S PO X
00903 DC S PO X
00910 UT S PO X
00951 WI S PO X
00952 IL S PO X
00953 MI S PO X
02050 CA S P
05130 ID S PO X
05440 TN S PO X
05535 NC S PO X
10230 CT S PO X
10240 MN S PO X
10250 MS S PO X
10490 VA S
14330 NY S PO X
16360 OH S P X
16510 WV S P X
31140 CA S P X
31142 ME
31143 MA
31144 NH
31145 VT
KEY: X=Policy contained column criteria; Shaded Box=Policy did not contain column criteria; NP=No policy; G=Policy specified
covered diagnoses in general way; S=Policy specified covered diagnosis in clear and specific way; PO=Policy specified
physicians and other provider types licensed by State to prescribe medication; P=Policy only specified physicians
13 A P P E N D I XA   
T A B L E  4:  P S Y C H O L O G I C A L  T E S T I N G 
Carrier  Utilization  Diagnosis  Qualified Providers  Documentation Requirements 
Specified Number of  Specified Number of  How LMRP  Indicated Type Or  Presence  Specific  Test Results  Report  Time 
Hours That May Be  Services That May Be  Specified Covered  Types That May  Or Signs of  Tests  and/or  Interpreting  Involved 
Number  State  Billed Per Service  Provided Per Year  Diagnoses  Render Service  Mental Illness  Performed  Test Scores  Test Results  In Testing 
00510  AL  G  X  X  X  X  X 
00511  GA  G  X  X  X  X  X 
00520  AR  G  X  X  X  X  X 
00521  NM  G  X  X  X  X  X 
00522  OK  G  X  X  X  X  X 
00523  MO  G  X  X  X  X  X 
00528  LA  G  X  X  X  X  X 
00590  FL  X  X  X 
00630  IN  X  S  X  X  X  X 
00650  KS  S  X  X  X  X 
00651  MO  S  X  X  X  X 
00655  NE  S  X  X  X  X 
00660  KY  X  S  X  X  X  X  X 
00751  MT  G  X  X  X  X  X 
00801  NY  G  X  X  X  X  X 
00803  NY  G  X  X  X  X  X 
00820  ND  G  X  X  X  X  X 
00824  CO  G  X  X  X  X  X 
00825  WY  G  X  X  X  X  X 
00826  IA  G  X  X  X  X  X 
00831  AK  G  X  X  X  X  X 
00832  AZ  G  X  X  X  X  X 
00834  NV  G  X  X  X  X  X 
00835  OR  G  X  X  X  X  X 
00836  WA  G  X  X  X  X  X 
00860  NJ  X  S  X  X  X  X  X 
00865  PA  X  S  X  X  X  X  X 
00870  RI  NP  NP  NP  NP  NP  NP  NP  NP  NP 
00880  SC  X  X 
00889  SD  G  X  X  X  X  X 
00900  TX  X  X  X  X  X 
00901  MD  X  X  X  X  X 
00902  DE  X  X  X  X  X 
00903  DC  X  X  X  X  X 
00910  UT  S  X  X  X  X  X 
00951  WI  X  S  X  X  X  X  X  X 
00952  IL  G  X  X  X  X  X 
00953  MI  G  X  X  X  X  X 
02050  CA  S  X  X  X 
05130  ID  G  X  X  X  X  X 
05440  TN  G  X  X  X  X  X 
05535  NC  G  X  X  X  X  X 
10230  CT  S  X  X  X  X  X 
10240  MN  X  X  X  X  X 
10250  MS  X  X  X  X  X 
10490  VA  X  S  X  X  X  X  X 
14330  NY  G  X  X  X  X  X 
16360  OH  NP  NP  NP  NP  NP  NP  NP  NP  NP 
16510  WV  NP  NP  NP  NP  NP  NP  NP  NP  NP 
31140  CA  NP  NP  NP  NP  NP  NP  NP  NP  NP 
31142  ME  X  X  S  X 
31143  MA  X  X  S  X 
31144  NH  X  X  S  X 
31145  VT  X  X  S  X 
KEY:  X=Policy contained column criteria; Shaded Box=Policy did not contain column criteria; NP=No policy; G=Policy specified covered diagnoses in 
general way; S=Policy specified covered diagnosis in clear and specific way 
14 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XB   
Descriptions of Mental Health Services Reviewed 
Individual Psychotherapy 
90804	 Individual psychotherapy, insight oriented, behavior modifying, and/or supportive, in an 
office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient. 
90805  Same as procedure 90804, but with medical evaluation and management services. 
90806	 Individual psychotherapy, insight oriented, behavior modifying, and/or supportive, in an 
office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient. 
90807  Same as procedure 90806, but with medical evaluation and management services. 
90808	 Individual psychotherapy, insight oriented, behavior modifying, and/or supportive, in an 
office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient. 
90809  Same as procedure 90808, but with medical evaluation and management services. 
Group Psychotherapy 
90853  Group psychotherapy (other than of a multiple-family group). 
Pharmacologic Management 
90862	 Pharmacologic management, including prescription, use, and review of medication with 
no more than minimal medical psychotherapy. 
Psychological Testing 
96100	 Psychological testing (includes psychodiagnostic assessment of personality, 
psychopathology, emotionality, intellectual abilities, e.g., WAIS-R (Wechsler Adult 
Intelligence Scale Revised), Rorschach, MMPI (Minnesota Multiphasic Personality 
Inventory)) with interpretation and report, per hour. 
15 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
Local Medical Review Policy Format

Medicare Program Integrity Manual 
Exhibit 6 - LMRP Format - (Rev. 14, 09-26-01) 
Contractor's Policy Number 	 Enter a unique policy identifier that the policy 
author designates. The numbering system 
is entirely up to the contractor and is used to 
catalog the policy for internal use. 
Contractor Name 	 The contractor name is the proper name assigned 
by CMS and used in the Contractor Report of 
Workload Data (CROWD) system. This is a 
mandatory field. 
Contractor Number	 The contractor number is the proper name 
assigned by CMS and used in the CROWD 
system. Include only one contractor number. This 
is a mandatory field. 
Contractor Type	 Indicate if this policy is for a fiscal intermediary 
(FI), carrier, regional home health intermediary 
(RHHI) or durable medical equipment regional 
carrier (DMERC). Select only one contractor 
type. This is a mandatory field. 
LMRP Title 	 Enter a brief, one line description of the topic or 
subject matter of the policy. The subject identifies 
the name of the medical policy. This field is used in 
the Keyword Search function for researching and 
drafting policies. To improve identifying your 
policies, try not to use special characters such as 
parentheses, slashes, and ellipses in this field. Only 
use these characters when absolutely necessary. 
This is a mandatory field. 
16 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
AMA CPT Copyright Statement 	 Include the following statement in each LMRP that 
contains CPT codes. "CPT codes, descriptions 
and other data only are copyright 2001 American 
Medical Association (or such other data of 
publication of CPT). All Rights Reserved. 
Applicable FARS/DFARS Clauses Apply." 
CMS National Coverage Policy 	 Indicate any associated CMS National Coverage 
Determination or Coverage Provision in an 
Interpretive Manual. Include a description if a 
National Coverage Determination or Provision is 
being expanded, adds greater clarification and/or 
codes. This is a mandatory field. 
Primary Geographic Jurisdiction	 The geographical area to which the LMRP will 
apply. For carriers and DMERCs, this jurisdiction 
is usually established based upon the contractor 
number. For RHHIs and FIs, this jurisdiction is 
established based upon the contractor number but 
may not include all States within CMS established 
jurisdiction. For example, an FI with the primary 
geographic jurisdiction of Connecticut, Michigan 
and New York may only develop a LMRP for 
Connecticut and not Michigan or New York. 
Contractors must indicate the primary jurisdiction 
to which this policy applies. This is a mandatory 
field. 
Secondary Geographic Jurisdiction 	 RHHIs and FIs may also have a secondary 
geographic jurisdiction for those facilities that 
nominate to have the FI or RHHI process their 
claims. The secondary geographic jurisdiction is 
the State in which the provider is located. Include 
all States for the providers to which this policy 
applies. 
CMS Region 	 List the region that retains oversight of the 
Medicare contractor's LMRP development 
process. Include only one region. This is a 
mandatory field. 
17 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
CMS Consortium  List the consortium for the regional office listed 
above. Include only one consortium. This is a 
mandatory field. 
DMERC Region LMRP Covers  List the region that this policy covers. This is a 
mandatory field for DMERCs only. 
Original Policy Effective Date  List the original date this policy became effective. 
For example, all policy rules, requirements and 
limitations became effective for services performed 
on and after this date. The format is 
MM/DD/YYYY. This is a mandatory field. 
Original Policy Ending Date  The date for which the policy is no longer effective. 
For example, all policy rules, 
requirements and limitations within this policy are 
no longer effective for services 
performed after this date. This date may be the 
same as, but not before the final 
revision ending effective date. The format is 
MM/DD/YYYY. This is a mandatory field 
for terminated policies. 
Revision Effective Date  The beginning date for which a revision becomes 
effective. For example, all policy 
rules, requirements and limitations within this 
revision are effective for services performed after 
this date. The format is MM/DD/YYYY. This is a 
mandatory field for revised policies. 
Revision Ending Date  The date for which this revision is no longer 
effective. For example, all policy rules, 
requirements, and limitations within this revision are 
no longer effective for services performed after this 
date. The format is MM/DD/YYYY. This is a 
mandatory field if a revised policy is itself 
subsequently revised or if a revised policy is 
terminated without a subsequent revision. 
18 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
LMRP Description 	 Characterize or define the item/service and explain 
how it operates or is performed. 
Use this field to enhance the policy subject. This is 
a mandatory field. 
Indications and Limitations of  List the general indications for which an 
Coverage and/or Medical Necessity 	 item/service is covered and/or considered 
reasonable and necessary. Also, list limitations 
such as least costly alternative reductions. This is a 
mandatory field. 
CPT/HCPCS Section and  Define the CPT/HCPCS section to which the 
Benefit Category 	 policy applies. Also state the appropriate benefit 
category. For example: physician services, DME, 
diagnostic services, prosthetic devices, evaluation 
and management, medicine, pathology and 
laboratory, radiology, nuclear, ultrasound and 
surgery. This is a mandatory field. 
Type of Bill Code 	 Enter the related type of bill codes for the item, 
service or procedure. Type of bill codes apply to 
FIs only. This is a mandatory field for FIs and 
RHHIs. 
Revenue Codes 	 Enter the related revenue code for the item, service 
or procedure. Revenue codes apply to FIs only. 
This is a mandatory field for FIs and RHHIs. 
CPT/HCPCS Codes 	 Enter the related HCPCS codes and any 
appropriate modifiers for the item/service. You 
may list the codes as a range. A policy may be 
associated with one or many HCPCS codes 
or a combination of all these. This is a mandatory 
field. 
Not Otherwise Classified (NOC) 	 Use this field in the absence of HCPCS codes. List 
the NOC code and the classified codes associated 
text. This is a mandatory field. 
19 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
ICD-9 Codes that Support  List the ICD-9 codes or code ranges, using 
Medical Necessity 	 maximum specificity, for which the item/service is 
generally covered, and/or considered medically 
necessary. A policy can be associated with one or 
many diagnosis codes, one or many ranges of 
diagnosis codes, or a combination of all of these. 
This is a mandatory field. 
Diagnoses that Support Medical Necessity 	 In the absence of ICD-9 codes, include the 
medical diagnoses that support the medical 
necessity for the item, service or procedure. 
ICD-9 Codes that DO NOT Support  List the ICD-9 codes that do not support the 
Medical Necessity 	 medical necessity of the service. Use this field 
when developing policies using an "exclusionary" 
approach in writing LMRP for which there are 
only limited exceptions of ICD-9 codes that would 
not support the medical necessity of the service. 
Diagnoses that DO NOT Support  In the absence of ICD-9 codes that do not support 
Medical Necessity 	 medical necessity, include the 
medical diagnoses that will not support medical 
necessity. Use this field when developing policies 
using an "exclusionary" approach in writing LMRP 
for which there are only limited exceptions of 
diagnoses that would not support the medical 
necessity of the service. 
Reasons for Denials 	 Indicate the specific situations under which an 
item/service will always be denied. Also, list the 
reasons for denial such as "investigational, 
cosmetic, routine screening, dental, program 
exclusion, otherwise not covered, or never 
reasonable and necessary." This is a mandatory 
field. 
20 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
Noncovered ICD-9 Codes	 If an item/service is always denied for a certain 
ICD-9 code, list the ICD-9 code(s) or code 
range(s) and narrative that are never covered. A 
policy can be associated with one or many 
noncovered diagnosis codes, one or many ranges 
of diagnosis codes or a combination of all of these. 
Noncovered Diagnosis  List the medical diagnoses that are not covered. 
Coding Guidelines	 Describe the relationships between codes and 
define how items/services are billed. Include 
information about the units of service, place of 
service, HCPCS modifiers, etc. An example of an 
appropriate coding technique is "use CPT xxxxx to 
bill this item/service rather than yyyyy." Include 
payment issues and payment considerations in the 
indications and limitations of coverage section. 
Documentation Requirements 	 Describe specific information from the medical 
records or other pertinent information 
that would be required to justify the item/service. 
For example, progress notes, pathology report, 
certificates of medical necessity (CMN), or 
photographs. Give instructions as to how 
Electronic Media Claim billers should submit 
documentation. 
Utilization Guidelines 	 Include information concerning the typical or 
expected utilization for the service. This is an 
optional field. 
Other Comments 	 Include information not included in other field 
sections. There is NO maximum field length. 
21 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
Sources of Information and  List the information sources, pertinent references 
Basis for Decision 	 (other than national policy) and other clinical or 
scientific evidence reviewed in the development of 
this policy. Cite, for example: Agency for Health 
Care Policy and Research (AHCPR) guidelines, 
position papers released by specialty societies or 
other sources used during the development of this 
policy. Also include the basis for your coverage 
decision and references that may apply. This is a 
mandatory field. 
Advisory Committee Notes	 All contractors must include the following 
information regarding the development of 
the LMRP: the meeting date on which the policy 
was discussed with the advisory 
committee. This is a mandatory field for those 
contractors who hold meetings. 
Start Date of Comment Period	 Enter the date the LMRP was released for 
comment. Use MM/DD/YYYY as the format. 
This is a mandatory field. 
End Date of Comment Period 	 Enter the date the comment period ended. Use 
MM/DD/YYYY as the format. This is a 
mandatory field. 
Start Date of Notice Period 	 Enter the date the medical community was notified 
about the LMRP. Use MM/DD/YYYY as the 
format. When no day is provided, enter 01 as the 
day. This is a mandatory field. 
22 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XC   
Revision History 	 The revision history includes the revision number, 
the effective date of the revision and an explanation 
of the revisions made to the policy. Any revision to 
LMRP that increase restrictions on coverage 
requires the usual notice and comment period. 
Revisions to utilization guidelines that increase 
restrictions on coverage are also subject to the 
notice and comment period. The revision number 
is a unique identifier that allows users to recognize 
if a policy is changed from its original form. The 
numbering system is entirely up to the contractor 
and is used to catalog the policy for your internal 
use. The revision dates are listed with the most 
recent revision date listed first. Use 
MM/DD/YYYY as the format. This is a 
mandatory field for revisions. 
All LMRPs must include the following paragraph: 
"This policy does not reflect the sole opinion of the contractor or contractor medical director. Although 
the final decision rests with the contractor, this policy was developed in cooperation with advisory 
groups, which includes representatives from [fill in appropriate specialty name]." 
23 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XD   
Selected OIG Reports on Medicare Mental Health Services 
Nursing Facilities 
Medicare Payments for Psychiatric Services in Nursing Homes: A Follow-up, OEI-02-99-00140 
Mental Health Services in Nursing Facilities, OEI-02-91-00860 
Acute Care and Psychiatric Specialty Hospitals 
Review of Outpatient Psychiatric Services Provided by Provena St. Joseph Hospital for the Period 
September 1, 1996 through November 30, 1997, A-05-00-00034 
Review of Outpatient Psychiatric Services Provided by Tomball Regional Hospital for Fiscal Year 
Ended June 30, 1998, A-06-99-00014 
Review of Outpatient Psychiatric Services Provided by the Waterbury Hospital for the Fiscal Year 
Ending September 30, 1997, A-01-99-00501 
Review of Outpatient Psychiatric Services Provided by the Elliot Hospital for the Fiscal Year Ending 
June 30, 1998, A-01-99-00502 
Ten-State Review of Outpatient Psychiatric Services at Acute Care Hospitals, A-01-99-00507 
Review of Outpatient Psychiatric Services Provided by the Danbury Hospital for Fiscal Year Ending 
September 30, 1997, A-01-99-00518 
Review of Outpatient Psychiatric Services at Psychiatric Hospitals for Calender Year 1998, 
A-01-99-00530 
Review of Outpatient Psychiatric Services Provided by St. Vincents Hospital for Calendar Year 
Ended December 31, 1997, A-02-99-01010 
Review of Outpatient Psychiatric Services Provided by St. Lukes-Roosevelt Hospital for Calendar 
Year Ended December 31, 1997, A-02-99-01016 
Review of Outpatient Psychiatric Services Provided by the Franklin Medical Center for the Fiscal Year 
Ending September 30, 1996, A-01-98-00503 
24 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I XD   
Psychiatric Outpatient Services: The Newton-Wellesley Hospital, A-01-98-00506 
Psychiatric Outpatient Services: The Arbour-HRI Hospital, A-01-97-00526 
Partial Hospitalization Programs 
Review of Partial Hospitalization Services and Fiscal Year 1997 Cost Report - New Center 
Community Mental Health Services, Detroit, Michigan, A-05-00-00004 
Results of Review of Americas Behavioral Health Center, A-04-98-01192 
Audit of the Medicare Partial Hospitalization Program at Mental Health Corporation of Denver, A-07-
98-01263 
Five-State Review of Partial Hospitalization Programs at Community Mental Health Centers, 
A-04-98-02145 
Review of Partial Hospitalization Services Provided Through Community Mental Health Centers, A-
04-98-02146 
Review of St. Francis Behavioral Health Centers Partial Hospitalization Program, 
A-04-97-02141 
Review of St. Jude Behavioral Health Centers Partial Hospitalization Program, A-04-97-02142 
Review of Partial Hospitalization Services and Audit of Medicare Cost Report for Community 
Behavioral Services, a Florida Community Mental Health Center, A-04-96-02118 and 
A-04-96-02124 
Other Outpatient Settings: Practitioners Offices, Community Mental Health 
Centers, Beneficiaries Homes, and Custodial Care Facilities 
Medicare Part B Payments for Mental Health Services, OEI-03-99-00130 
25 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
Comments on the Draft Report

26 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
Comments from the

Centers for Medicare & Medicaid Services

27 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
28 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
Comments from the

American Association for Geriatric Psychiatry

29 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
30 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
31 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
32 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
Comments from the

American Psychiatric Association

33 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
34 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
35 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A P P E N D I X  
36 
Carriers Policies for Mental Health Services  OEI-03-99-00132  A C K N O W L E D G M E N T S  
This report was prepared under the direction of Robert A. Vito, Regional Inspector General for 
Evaluation and Inspections in Philadelphia, PA and Linda M. Ragone, Deputy Regional Inspector 
General. Other principal Office of Evaluation and Inspections staff who contributed include: 
Amy Sernyak, Project Leader  Bambi Straw, Program Specialist 
Lauren McNulty, Lead Analyst 
37 
Carriers Policies for Mental Health Services  OEI-03-99-00132