Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

INSPECTOR GENERAL 

MAY 2002 

OEI-03-99-00132 

Medicare Carriers’ Policies 

for Mental Health Services 
OFFICE OF INSPECTOR GENERAL

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 OIG’s 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. 
EXECUTIVE SUMMARY 

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 carrier’s policy to the next. 

Carriers’ Policies for Mental Health Services i 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 patient’s 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. 

Carriers’ Policies for Mental Health Services ii 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 Association’s Current Procedural 

Terminology. 

Carriers’ Policies for Mental Health Services iii OEI-03-99-00132 
TABLE OF CONTENTS 

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

Carriers’ Policies for Mental Health Services iv OEI-03-99-00132 
INTRODUCTION 

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. 

Carriers’ Policies for Mental Health Services 1 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. 

Carriers’ Policies for Mental Health Services 2 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 President’s Council on Integrity and Efficiency. 

Carriers’ Policies for Mental Health Services 3 OEI-03-99-00132 
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. 

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) 

Number Name State 

Individual 

Therapy 

Group 

Therapy 

Pharmacologic 

Management 

Psychological 

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 carrier’s 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. 

Carriers’ Policies for Mental Health Services 4 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 patient’s 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. 

Carriers’ Policies for Mental Health Services 5 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 patient’s 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 patient’s 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. 

Carriers’ Policies for Mental Health Services 6 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 patient’s 

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 patient’s 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 patient’s test results. In 

addition, the majority of carriers’ policies required documentation of the time involved in 

administering, scoring, interpreting, and reporting psychological test results. 

Carriers’ Policies for Mental Health Services 7 OEI-03-99-00132 
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. 

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’ 

Carriers’ Policies for Mental Health Services 8 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 Association’s Current Procedural 

Terminology. 

Carriers’ Policies for Mental Health Services 9 OEI-03-99-00132 
APPENDIX 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. 

Carriers’ Policies for Mental Health Services 10 OEI-03-99-00132 
APPENDIX A 

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 

Number State 

Guidelines 

Provided 

Prolonged 

Treatment = More 

Than 20 Sessions 

How LMRP 

Specified Covered 

Diagnoses 

How LMRP 

Specified Qualified 

Provider Types 

Certain Provider Types 

Cannot Bill Evaluation 

and Management Codes 

Therapy 

Goals 

Time 

Spent 

Estimated 

Duration of 

Treatment 

Therapy Will 

Stabilize 

Chronic Illness 

Patient 

Diagnosis 

Date 

of 

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 

Carriers’ Policies for Mental Health Services 11 OEI-03-99-00132 
APPENDIX A 

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 

Number State 

Specified Number of 

Services That May 

Be Billed Per Year 

How LMRP 

Specified Covered 

Diagnoses 

Specific List of 

Qualified 

Provider Types 

Therapy 

Goals 

Estimated 

Duration of 

Treatment 

Patient 

Diagnosis 

Therapy Will 

Stabilize 

Chronic Illness 

Date 

of 

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 

Carriers’ Policies for Mental Health Services 12 OEI-03-99-00132 
13

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 P O X

00511 GA S P O X

00520 A R S P O X

00521 N M S P O X

00522 OK S P O X

00523 M O S P X

00528 LA S P O X

00590 F L N P N P N P N P N P

00630 IN S P O

00650 K S X S X

00651 M O X S X

00655 N E X S X

00660 K Y S P O

00751 M T G P O X

00801 N Y S P O X

00803 N Y S P O X

00820 N D S P O X

00824 C O S P O X

00825 W Y S P O X

00826 IA S P O X

00831 A K S P O X

00832 AZ S P O X

00834 N V S P O X

00835 O R S P O X

00836 W A S P O X

00860 N J S P O X

00865 P A S P O X

00870 R I N P N P N P N P N P

00880 S C N P N P N P N P N P

00889 S D S P O X

00900 TX S P O X

00901 M D S P O X

00902 D E S P O X

00903 D C S P O X

00910 U T S P O X

00951 W I S P O X

00952 IL S P O X

00953 M I S P O X

02050 C A S P

05130 ID S P O X

05440 T N S P O X

05535 N C S P O X

10230 C T S P O X

10240 M N S P O X

10250 M S S P O X

10490 V A S

14330 N Y S P O X

16360 O H S P X

16510 W V S P X

31140 C A S P X

31142 M E

31143 M A

31144 N H

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
APPENDIX A 

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 

Number State 

Specified Number of 

Hours That May Be 

Billed Per Service 

Specified Number of 

Services That May Be 

Provided Per Year 

How LMRP 

Specified Covered 

Diagnoses 

Indicated Type Or 

Types That May 

Render Service 

Presence 

Or Signs of 

Mental Illness 

Specific 

Tests 

Performed 

Test Results 

and/or 

Test Scores 

Report 

Interpreting 

Test Results 

Time 

Involved 

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 

Carriers’ Policies for Mental Health Services 14 OEI-03-99-00132 
APPENDIX B 

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. 

Carriers’ Policies for Mental Health Services 15 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 16 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 17 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 18 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 19 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 20 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 21 OEI-03-99-00132 
APPENDIX C 

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. 

Carriers’ Policies for Mental Health Services 22 OEI-03-99-00132 
APPENDIX C 

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]." 

Carriers’ Policies for Mental Health Services 23 OEI-03-99-00132 
APPENDIX D 

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. Vincent’s Hospital for Calendar Year 

Ended December 31, 1997, A-02-99-01010 

Review of Outpatient Psychiatric Services Provided by St. Luke’s-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 

Carriers’ Policies for Mental Health Services 24 OEI-03-99-00132 
APPENDIX D 

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 America’s 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, A04-98-02146 

Review of St. Francis Behavioral Health Center’s Partial Hospitalization Program, 

A-04-97-02141 

Review of St. Jude Behavioral Health Center’s 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 

Carriers’ Policies for Mental Health Services 25 OEI-03-99-00132 
APPENDIX 

Comments on the Draft Report

Carriers’ Policies for Mental Health Services 26 OEI-03-99-00132 
APPENDIX 

Comments from the

Centers for Medicare & Medicaid Services

Carriers’ Policies for Mental Health Services 27 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 28 OEI-03-99-00132 
APPENDIX 

Comments from the

American Association for Geriatric Psychiatry

Carriers’ Policies for Mental Health Services 29 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 30 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 31 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 32 OEI-03-99-00132 
APPENDIX 

Comments from the

American Psychiatric Association

Carriers’ Policies for Mental Health Services 33 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 34 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 35 OEI-03-99-00132 
APPENDIX 

Carriers’ Policies for Mental Health Services 36 OEI-03-99-00132 
ACKNOWLEDGMENTS 

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 

Carriers’ Policies for Mental Health Services 37 OEI-03-99-00132