Article - Billing and Coding: Psychiatry and Psychology Services (A57480)

CMS National Coverage PolicySocial Security Act 1861(s) Medical and Other Health Services42 CFR 410.73  410.76 describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.CMS Publication 100-02:Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services:160 Clinical Psychologist Services170 Clinical Social Worker (CSW) Services180 Nurse-Midwife (CNM) Services190 Physician Assistant (PA) Services200 Nurse Practitioner (NP) Services210 Clinical Nurse Specialist (CNS) ServicesCMS Publication 100-03:Medicare National Coverage Determinations (NCD) Manual,Chapter 1  Coverage Determinations, Part 1:30.1 Biofeedback TherapyCMS Publication 100-04:Medicare Claims Processing Manual,Chapter 12  Physician/Nonphysician Practitioners:110 Physician Assistant (PA) Services Payment Methodology120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology120.1 Limitations for Assistant-at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists150 Clinical Social Worker (CSW) Services160 Independent Psychologist Services170 Clinical Psychologist Services170.1 Payment210 Outpatient Mental Health Treatment LimitationArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34616 Psychiatry and Psychology Services.General CodingPsychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. References to providers include physicians and non-physicians, such as clinical psychologists, independent psychologists, nurse practitioners, clinical nurse specialists and physician assistances when the services performed are within the scope of their state license and clinical practice/education.Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. Psychiatric service CPT codes should not be used when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes is more appropriate.Interactive Complexity (90785) is an add-on code specific for psychiatric services and refers to communication difficulties during the psychiatric procedure. Add-on codes may only be reported in conjunction with other codes, never alone.The specific communication difficulties are present with patients who typically:Have other individuals legally responsible for their care, such as minors or adults with guardians, orRequest others to be involved in their care during the visit, such as adults accompanied by one or more participating family members or interpreter or language translator, orRequire the involvement of other third parties, such as child welfare agencies, parole or probation officers, or schools.Interactive complexity may be reported with psychiatric procedures when at least one of the following communication difficulties is present:The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.Caregiver emotions/behavior that interfere with implementation of thetreatment plan.Evidence/disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.Use of play equipment, physical devices, interpreter, or translator to overcome significant language barriers.Do not report the CPT add-on code for Interactive Complexity code in conjunction with Psychotherapy for crisis codes or in conjunction with E/M services when no psychotherapy service is also reported.II. Service-specific Guidelines:Psychiatric Diagnostic Interview Examination (90791, 90792).A psychiatric diagnostic evaluation or a psychiatric diagnostic evaluation with medical services can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended break in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. This contractor considers an extended break as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.An E/M service may be substituted for the initial interview procedure provided required elements of the E/M service billed are fulfilled. E/M services require, in addition to the interview and examination, the provision of a written opinion and/or advice. E/M CPT codes do not include a psychotherapy service.CPT Codes 90832-90838 represent psychotherapy.Psychotherapy without medical evaluation and management services are reported as 90832, 90834 and 90837. Psychotherapy with medical evaluation and management services are reported with codes for E/M services plus a psychotherapy add-on code (90833; 90836; 90838). For psychotherapy sessions lasting longer than 90 minutes, reimbursement will only be made if the report is supported by the medical record documenting the face-to-face time spent with the patient and the medical necessity for the extended time.CPT Codes 90846 and 90847 represent family psychotherapy services for the treatment of mental disorders. They should not be used when the service performed is taking a family history or E/M counseling services. E/M counseling services should be coded with the appropriate E/M CPT code according to the time involved. Family counseling does not include the supervision of or therapy with professional caretakers or staff.CPT code 90853 represents group therapy. When medically indicated, the interactive complexity add-on code (+90785) may be billed in conjunction with this code.CPT Code 90839 is for psychotherapy crisis for the first 60 minutes and code 90840is for each additional 30 minutes. These codes are reported by themselves and maynot be reported with 90791, 90792, 90832-90838, 90785-90899.Medicare does not cover biofeedback for the treatment of psychosomatic disorders.III. Billing GuidelinesTo report both E/M and psychotherapy, the two services must be significant and separately identifiable.A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.Site of service is not applicable to psychotherapy. Psychotherapy codes are payable in all settings.IV. Other InformationCPT codes 90885, 90887, 90889 are considered incidental services and are not separately payable.