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

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):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  aministered) 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.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15:60.1 Incident to Physician's Professional Services60.2 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 (NCD) Manual,Chapter 1:70.3 Physician's Office Within an Institution - Coverage of Services and Supplies Incident to a Physicians ServicesCMS 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) Services.120.1 Direct Billing and Payment for Nonphysician Practitioner Services Furnished to Hospital Inpatients and Outpatients150 Clinical Social Worker (CSW) Services160 Independent Psychologist Services160.1 Payment for Independent Psychologist Services170 Clinical Psychologist Services.170.1 Payment for Clinical Psychologist Services