Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)

CMS National Coverage PolicyN/AArticle TextAbstract:"Incident to" a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1) The "incident to" provision may also apply to coverage for psychological services furnished "incident to" the professional services of certain non-physician practitioners including clinical psychologists, nurse practitioners, and clinical nurse specialists (CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.2). Section 1862(a)(1)(A) of the Social Security Act governs payment for the provision of medical care to Medicare beneficiaries.The training requirements and state licensure or authorization of individuals who perform psychological services are intended to ensure an adequate level of expertise in the cognitive skills required for the performance of diagnostic and therapeutic psychological services. Therefore, only the types of individuals listed later in this policy are considered qualified to perform medically necessary psychological services addressed in this policy. Delegation of diagnostic and therapeutic psychological services to personnel not performing within the scope of practice as authorized by state law, under the "incident to" provision, would bypass the safeguards afforded by professional credentialing and state licensure requirements. Such delegated services under the "incident to" provision would be inappropriate, unreasonable, and medically unnecessary, and therefore not covered by Medicare.Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B. To be considered an employee (auxiliary personnel) for purposes of this section, the nonphysician performing an "incident to" service is defined asany individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician or legal entity that employs or contracts with the physician.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B).Indications and Limitations:For psychology services rendered under the "incident to" provision, the billing provider must first evaluate the patient personally and then initiate the course of treatment. The appropriately trained therapists may then render psychological services to the patient under the billing provider's general supervision.While a variety of psychiatric/psychotherapeutic techniques are recognized for coverage, the services must be performed by persons authorized by Medicare and licensed by their state to render these services.Only the types of practitioners listed below, when they are performing within their scope of clinical practice as authorized under state law, are qualified to perform the indicated diagnostic and/or therapeutic psychological services under the "incident to" provision.Doctorate or Masters level Clinical Psychologist: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90880, 90899Doctorate or Masters level Clinical Social Worker: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Clinical Nurse Specialist (CNS): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Nurse Practitioner (NP): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Marriage and Family Therapist (MFT): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451Mental Health Counselor (MHC): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451The psychological services referenced in the above HCPCS codes may only be delegated to employees who qualify for one of the categories of individuals listed above. For example, a psychiatrist may hire a clinical social worker to perform services designated by the HCPCS codes listed in #2 above. Individuals who are performing services "incident to" a qualified Medicare practitioner are not required to be separately enrolled as an independent practitioner in Medicare.It is not permissible for the billing provider to hire and supervise a professional whose scope of practice is outside the provider's own scope of practice as authorized under State law, or whose professional qualifications exceed those of the "supervising" provider. For example, a certified nurse-midwife (CNM) may not hire a psychologist and bill for that psychologist's services under the "incident to" provision, because a psychologist's services are not integral to a CNM's personal professional services and are not regularly included in the CNM's bill. Even though sections 1861(s)(2)(l) and 1861(gg) (l) of the Social Security Act authorize coverage for services furnished "incident to" a CNM's services, psychological services are not commonly furnished in CNM's offices nor within their scope of practice. Similarly, even though section 1861(s)(2)(K)(iv) authorizes coverage for services furnished "incident to" a physician assistant's services, a physician assistant would not be qualified to supervise psychological services performed by the types of individuals listed above.Individuals who are not licensed or otherwise authorized by state law to provide psychological services may not provide psychological services under the "incident to" provision. This level of professional credentialing is necessary to furnish appropriate medically necessary services under the "incident to" provision.Psychological services furnished to Medicare beneficiaries under the "incident to" provision by individuals other than those listed above are not covered. (Note: the standards for professional credentialing are higher for these services billed to Medicare Part B than for similar services performed by other mental health professionals not under the "incident to" provision and billed to Medicare Part A. Under the "incident to" provision, services are performed in the place of the billing provider. In order for services performed and billed under the "incident to" provision to be commensurate with the services performed by the billing provider, and therefore medically necessary, this higher standard of professional credentialing is necessary.)Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B. This also applies to the services of certain non - physician practitioners who are being licensed by the states under various programs to assist or act in the place of the physician, including nurses, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors and other therapists.General Supervision - means the procedure is furnished under the physicians overall direction and control, but the physicians presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15).Services and supplies incident to a physicians service in a physician directed clinic or group association are generally the same as those described for the office setting(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.3).For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of physician-employed auxiliary personnel as services incident to physicians' services undersection 1891(s)(2)(A)of the Act. Such services can be covered only under the hospital outpatient or inpatient benefit and payment for such services can be made to only the hospital by a Medicare Part A MAC (CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60).For "incident to" services to be covered when a physician's office is in an institution, theauxiliary medical personnel must be members of the office staff rather than of the institution's staff, and the cost of supplies must represent an expense to the physician's office practice. In addition, services performed by the employees of the physician outside the "office" area must be generally supervised by the physician. (In any setting, of course, supervision of auxiliary personnel in and of itself is not considered a "physician's professional service" to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to supervision, the physician must perform or have performed a personal professional service to the patient to which the services of the auxiliary personnel could be considered an incidental part). Denials for failure to meet any of these requirements would be based on 1861(s)(2)(A) of the Act.(CMS Pub 100-03;Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 1, 70.3)If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than a hospital or SNF), their services are covered incident to a physician's service only if there is general supervision.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 30, for complete instructions.General Coding Guidelines for Psychiatry and Psychology Services:Individual psychotherapy codes should be used only when the focus of treatment involves individual psychotherapy. These codes should not be used as generic psychiatric service codes when other codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.Charges for certain psychiatric services provided by hospital outpatient departments are submitted to the Part A MAC. Services of physicians, clinical psychologists, physician assistants, nurse practitioners, and clinical nurse specialists are billed to the Part B MAC. Services furnished incident to the professional services of clinical psychologists to hospital patients remain bundled with the facility services for payment purposes, with payment made to the hospital for such "incident to" services.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for Psychological Services Coverage Under the "Incident to" Provision are payable under Medicare Part B in settings other than a hospital or to a resident of a skilled nursing facility who are in a Part A stay.For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Information on state specific providers licensed or authorized to provide psychological services "incident to" a physician, clinical psychologist, clinical nurse specialist, or nurse practitioner (as defined in the "Indications" section above), can be found at respective State Web sites regarding the licensing and certification of mental health providers.Sources of Information:CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):