(Medicare Claims Processing Manual)

 Advising physician to use modifier 25 with the visit service;   Denying payment for the visit unless documentation has been provided; and   Paying for both the visit and the allergy shot if both are billed for.   For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means.  Effective for services rendered on or after that date, the gl obal surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117.  To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period.    Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services.  In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with t he visit code, indicating that the patients condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.   D. Reasonable Supply of Antigens   See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100- 02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.  210 - Outpatient Mental Health Treatment Limitation  (Rev. 2166, Issued: 02- 25-11, Effective: 03 -25-11, Implementation: 03- 25-11)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  This limitation is called the outpatient mental health treatment limitation (the limitation).  The 6 2.5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010 -  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).    January 1, 2012 -  December 31, 2012, the limitation percentage is 75%.  (Medicare pays 60% and the patient pays 40%).    January 1, 2013 -  December 31, 2013, the limitation percentage is 81.25%.  (Medicare pays 65% and the patient pays 35%).    January 1, 2014 -  onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).   For additional details concerning computation of the limitation, please see the examples under section 210.1 E.   210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    A. Status of Patient    The limitation is applicable to expenses incurred in connection with the treatment of an individual who is not an inpatient of a hospital.  Thus, the limitation applies to mental health services furnished to a person in a physicians office, in the patient s home, in a skilled nursing facility, as an outpatient, and so forth.  The term hospital in this context means an institution, which is primarily engaged in providing to inpatients, by or under the supervision of a physician(s):     Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons;     Rehabilitation services for injured, disabled, or sick persons; or     Psychiatric services for the diagnosis and treatment of mentally ill patients.    B. Disorders Subject to the Limitation    The term mental, psychoneurotic, and personality disorders is defined as the specific psychiatric diagnoses described in the International Classification of Diseases, 9th Revision (ICD -9), under the code range 290-319.    When the treatment services rendered are both for a psychiatric diagnosis as defined in the ICD -9 and one or more nonpsychiatric conditions, separate the expenses for the psychiatric aspects of treatment from the expenses for the nonpsychiatric aspects of treatment.  However, in any case in which the psychiatric treatment component is not readily distinguishable from the nonpsychiatric treatment component, all of the expenses are allocated to whichever component constitutes the primary diagnosis.    1. Diagnosis Clearly Meets Definition -  If the primary diagnosis reported for a particular service is the same as or equivalent to a condition described in the ICD9 under the code range 290- 319 that represents mental, psychoneurotic and personality disorders, the expense for the service is subject to the limitation except as described in subsection D.    2. Diagnosis Does Not Clearly Meet Definition -  When it is not clear whether the primary diagnosis reported meets the definition of mental, psychoneurotic, and personality disorders, it may be necessary to contact the practitioner to clarify the diagnosis.  I n deciding whether contact is necessary in a given case, give consideration to such factors as the type of services rendered, the diagnosis, and the individuals previous utilization history.    C. Services Subject to the Limitation    A/B MACs (B) must apply the limitation to claims for professional services that represent mental health treatment furnished to individuals who are not hospital inpatients by physicians, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists and physician assistants.  Items and supplies furnished by physicians or other mental health practitioners in connection with treatment are also subject to the limitation.    Generally, A/B MACs (B) must apply the limitation only to treatment services.   However, diagnostic psychological and neuropsychological testing services performed to evaluate a patients progress during treatment are considered part of treatment and are s ubject to the limitation.    D. Services Not Subject to the Limitation    1. Diagnosis of Alzheimers Disease or Related Disorder -  When the primary diagnosis reported for a particular service is Alzheimers Disease or an Alzheimers related disorder, A/B MACs (B) must look to the nature of the service that has been rendered in det ermining whether it is subject to the limitation.  Alzheimers disease is coded 331.0 in the International Classification of Diseases, 9th Revision, which is outside the code range 290- 319 that represents mental, psychoneurotic and personality disorders.  Additionally, Alzheimers related disorders are identified by A/B MACs (B) under ICD -9 codes that are within the 290- 319 code range (290.XX or others as A/B MACs (B) determine appropriate) or outside the 290- 319 code range as determined appropriate by A/ B MACs (B).  When the primary treatment rendered to a patient with a diagnosis of Alzheimers disease or a related disorder is psychotherapy, it is subject to the limitation.  However, typically, treatment provided to a patient with a diagnosis of Alzheimers Disease or a related disorder represents medical management of the patients condition (such as described under  CPT code 90862 or any successor code) and is not subject to the limitation.   CPT code 90862 describes pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.    2. Brief Office Visits for Monitoring or Changing Drug Prescriptions -  Brief office visits for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic and personality disorders are not subject to the limitation.  These visits are reported using HCPCS code M0064 or any successor code (brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic, and personality disorders).  Claims where the diagnosis reported is a mental, psychoneurotic, or personality disorder (other than a diagnosis specified in subsection A) are subject to the limitation except for the procedure identified by HCPCS code M0064 or any successor code.    3. Diagnostic Services -  A/B MACs (B) do not apply the limitation to psychiatric diagnostic evaluations and diagnostic psychological and neuropsychological tests performed to establish or confirm the patients diagnosis.  Diagnostic services include psychiatr ic diagnostic evaluations billed under CPT codes 90801 or 90802 (or any successor codes) and, psychological and neuropsychological tests billed under CPT code range 96101- 96118 (or any successor code range).   An initial visit to a practitioner for professional services often combines diagnostic evaluation and the start of therapy.  Such a visit is neither solely diagnostic nor solely therapeutic.  Therefore, A/B MACs (B) must deem the initial visit to be diagnostic so that the limitation does not apply.  Separating diagnostic and therapeutic components of a visit is not administratively feasible, unless the practitioner already has separately identified them on the bill.  Determining the entire visit to be thera peutic is not justifiable since some diagnostic work must be done before even a tentative diagnosis can be made and certainly before therapy can be instituted.  Moreover, the patient should not be disadvantaged because therapeutic as well as diagnostic ser vices were provided in the initial visit.  In the rare cases where a practitioners diagnostic services take more than one visit, A/B MACs (B) must not apply the limitation to the additional visits.  However, it is expected such cases are few.  Therefore, when a practitioner bills for more than one visit for professional diagnostic services, A/B MACs (B) may find it necessary to request documentation to justify the reason for more than one diagnostic visit.    4. Partial Hospitalization Services Not Directly Provided by a Physician or a Practitioner -  The limitation does not apply to partial hospitalization services that are not directly provided by a physician, clinical psychologist, nurse practitioner, clinical n urse specialist , or a physician assistant.  Partial hospitalization services are billed by hospital outpatient departments and community mental health centers (CMHCs) to A/B MACs (A).  However, services furnished by physicians, clinical psychologists, nurs e practitioners, clinical nurse specialists, and physician assistants to partial hospitalization patients are billed separately from the partial hospitalization program of services.   Accordingly, these professionals mental health services to partial hospitalization patients are paid under the physician fee schedule by A/B MACs (B) and may be subject to the limitation. (See chapter 4, section 260.1C).  5. Intensive Outpatient Services Not Directly Provided by a Physician or a Practitioner -  The limitation does not apply to intensive outpatient services that are not directly provided by a physician, clinical psychologist, nurse practitioner, clinical nurse s pecialist, or a physician assistant.  Intensive outpatient services are billed by hospital outpatient departments, community mental health centers (CMHCs), RHCs, FQHCs, and OTPs to A/B MACs (A).  However, services furnished by physicians, clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants to intensive outpatient patients are billed separately from the intensive outpatient program of services.   Accordingly, these professional s mental health services to intensi ve outpatient patients are paid under the physician fee schedule by A/B MACs (B) and may be subject to the limitation. (See chapter 4, section 261.1C).   E. Computation of Limitation    A/B MACs (B) determine the Medicare approved payment amount for services subject to the limitation.  They:     Multiply the approved amount by the limitation percentage amount;      Subtract any unsatisfied deductible; and,      Multiply the remainder by 0.8 to obtain the amount of Medicare payment. The beneficiary is responsible for the difference between the amount paid by Medicare and the full Medicare approved amount.