Article - Billing and Coding: Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians (A57054)

CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. Please see Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1861(s)(2)(A) of Title XVIII of the Social Security Act defines'medical and other health services' as "any of the following items or services: services and supplies (including drugs and biologicals which cannot, as determined in accordance with regulations, be self - administered) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;"Sections 1861(s)(2)(l) and 1861(gg)(l) of Title XVIII "incident to" a certified nurse midwife's (CNMW's) services.Section 1861(s)(2)(K)(iv) of Title XVIII of the Social Security Act authorizes coverage for services furnished "incident to" a physician assistant's services.Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Code of Federal Regulations:42 CFR 410.32 states that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license) and Medicare requirements.42 CFR 410.71 describes coverage of clinical psychologist services and supplies incident to a clinical psychologist.42 CFR 410.73-410.76 describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:60.1 Services and Supplies; Incident to Physician's Professional Services60.2 Services and supplies: Services of Nonphysician Personnel Furnished Incident to Physician's Services60.3 Incident to Physician's Service in Clinic60.4 Services Incident to a Physician's Service to Homebound Patients under General Physician Supervision160 Clinical Psychological Services170 Clinical Social Worker (CSW) Services210 Clinical Nurse Specialist (CNS) ServicesCMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1:70.3 Physician's Office Within an Institution - Coverage of Services and SuppliesCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12:110 Physician Assistant (PA) Services Payment Methodology110.3 PA Billing to Carrier120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS).120.1 NP and CNS "Direct Billing and Payment"150 Clinical Social Worker (CSW) Services160 Independent Psychologist Services160.1 Payment for Independent Psychologist Services170 Clinical Psychologist Services.170.1 Payment for Clinical Psychologist ServicesCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30:50.3 ABN ScopeArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL34539-Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians.General Coding Guidelines for Psychiatry and Psychology Services:Individual psychotherapy codes should be used only when the focus of treatment involves individual psychotherapy. These codes should not be used as generic psychiatric service codes when other codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.Charges for certain psychiatric services provided by hospital outpatient departments are submitted to the Part A MAC. Services of physicians, clinical psychologists, physician assistants, nurse practitioners, and clinical nurse specialists are billed to the Part B. Services furnished incident to the professional services of clinical psychologists to hospital patients remain bundled with the facility services for payment purposes, with payment made to the hospital for such "incident to" services.If the patient receives primarily psychotherapy along with an E/M service, and, in addition, pharmacological management at the same visit, the psychotherapy codes, which include evaluation and management, should be used. The pharmacological management is included as part of the E/M service by definition, and therefore, 90863 should not be billed in addition to the psychotherapy codes. Please refer to the CCI edits.Other Guidelines:Psychological services are covered in Comprehensive Outpatient Rehabilitation Facilities (CORFs).If the CORF treatment services rendered are for both a psychiatric condition and one or more nonpsychiatric conditions, separate the charges for the psychiatric aspects of treatment from the charges for the nonpsychiatric aspects. See the Medicare Claims Processing publication for specific instructions(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 12, Section 50.4).General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Non-coverage (ABN) Modifier 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.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)In addition to ordinary standards of good clinical documentation, the legible identity of the individual rendering the service with his/her professional credentials must be included in the documentation of each service and available in the medical record. Documentation of supervision by the physician/provider billing for the "incident to" services must be present in the medical record.Other Comments:For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for Psychological Services Coverage under the "Incident to" Provision for Physicians and Non-physicians services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)