LCD for Psychiatric Services-Outpatient Hospital based (L1372)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1372 

 

LCD Title 

Psychiatric Services-Outpatient Hospital based 

 

Contractor's Determination Number 

L1372 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/28/2000  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 12/09/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Statement



Admission to Hospital-based, outpatient Psychiatric programs is based on a need for evaluation, observation control and treatment of psychiatric symptoms. The intensity of service provided is dependent upon the patient's symptoms and ability to function in their environment. These patients, whose severity of symptoms are such that an intense, daily program as provided in a Partial Hospitalization Program(PHP) is not required, are appropriate for the outpatient setting.

Outpatient clinical services are to be provided to those patients who consent and are capable of actively participating in the services, and who demonstrate a reasonable expectation of improvement in their disorder or condition as a result of the active treatment provided. The condition should not be of a chronic nature.

Services Covered



1. Individual or Group Psychotherapy with physicians, psychologists or other mental health staff authorized by the State in which they practice. The state licensure or authorization must specify that the providers scope of practice includes the provision of clinical psychotherapy for the treatment of mental illness.

2. Occupational Therapy (OT) services are covered. To be eligible, the services must require the skills of a qualified Occupational Therapist or an Occupational Therapy Assistant. Services must not be recreational or diversionary.

3. Services of a licensed Clinical Social Worker, trained psychiatric registered nurse and other staff trained to work with psychiatric patients.

4. Drugs and biologicals furnished to outpatients for therapeutic purposes, but only if they cannot be self-administered. (CMS Pub 100-2, 6§20.4)

5. Activity therapies that are individualized and essential for the treatment of the patient's condition. There must be clear documentation that justifies the need for each and the services must not be recreational or diversionary.

6. Family Counseling Services. Counseling services with members of the household are covered only if the primary purpose of such counseling is the treatment of the patient's condition. (See Coverage Issues Manual, § 35-14)

7. Patient Education Programs in which the educational activities are directly related to the treatment of the patient. (See Coverage Issues Manual, § 80-1)

8. Diagnostic services for the purpose of diagnosing those individuals for whom it is necessary to determine functioning and interactions, to identify problem areas and to formulate a treatment plan. It is not expected that a patient who has been in a inpatient psychiatric program, or a partial program would require further diagnostic services. If further psychological testing is completed, there must be documentation in the clinical record supporting the need for those services.

The program is to be under the direction of a physician (M.D./D.O.) trained in the treatment of psychiatric disorders, and who is licensed by the State in which he/she practices

Incident to Physician Services



Services must be incident to physician services. To be covered as "incident to" physician services:


a. Outpatient clinical services are furnished during a course of treatment initiated by the physician, and under a physician's orders. The physician performs a psychiatric evaluation and established the treatment plan within 24 hours of admission, directs and supervises the treatment, and conducts subsequent professional services.

b. The services provided and related supplies must be furnished as an integral, although incidental, part of the physician's professional service in the course of diagnosis or treatment of an illness or injury.

c. When a physician writes an order for services and refers the patient to the outpatient psychiatric program, the physician must initiate the management of the course of treatment.

d. Diagnostic services are covered when provided by the hospital whether furnished in the hospital or at other locations. Outpatient therapeutic services, furnished incident to physician's services, are covered when furnished outside the hospital only if there is direct personal supervision by a physician. Thus, it may be necessary to distinguish between diagnostic and therapeutic services when services are provided outside the hospital.

e. The physician must routinely provide and document clinical supervision and direction to any therapist involved in the patient's treatment via the Master Treatment Plan.

f. There must be documentation that the attending physician participated in the management of the course of treatment of the patient.

 

Reasonable Expectation of Improvement



Services must be reasonable and necessary for the diagnosis and treatment of the patient's condition. This means the service provided must reasonably be expected to improve the patient's condition.

The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse which would require a higher level of care, and improve the patient's level of functioning.

It is not necessary that a course of therapy have as its goal, the restoration of the patient to the level of functioning exhibited prior to the onset of the illness, although this may be appropriate for some patients. For patients with long-term, chronic conditions, control of symptoms and maintenance of a functional level, to avoid further deterioration is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. (CMS Pub 100-2, 6§70) Meeting this criterion of improvement in patients with long-term, chronic conditions is measured by gradually reducing the treatment and measuring the effect on the patient. When stability can be maintained without further treatment or with less intensive treatment, it is determined that the "improvement" criterion has been met and the patient should be discharged from the Outpatient Psychiatric Services and transitioned to a less intensive treatment modality which may include Psychotherapy/Med Management on an intermittent basis.

Intensity of Services



In order for treatment to be medically necessary, treatment services must be delivered at the lowest level of intensity that still establishes and maintains improvement as defined above. Attempts at reducing the level of services must be made at appropriate intervals and documented to establish medical necessity for services.
 

 

Coverage Topic 

Mental Health Care (Outpatient)
 

 

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

 

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0250

Pharmacy-general classification

090X

Psychiatric/psychological treatments-general classification

0910

Psychiatric/psychological services-general classification

0914

Psychiatric/psychological services-individual therapy

0915

Psychiatric/psychological services-group therapy

0916

Psychiatric/psychological services-family therapy

0918

Psychiatric/psychological services-testing

 

 

CPT/HCPCS Codes 

The list of HCPCS Codes does not assure coverage of the specific services. Current coverage criteria apply.

Procedure code 90808 and 90821 indicate interventions lasting 75-80 minutes should not be routinely used. These codes are for rare circumstances and the medical record must define the exceptional conditions which support the medical necessity for the extended time period.

Procedure code 90899 is defined as "unlisted psychiatric service or procedure" and should not be used if the hospital provides the listed services below which have their own individual codes. If and when this code is used, an explanation and clinical rationale for its use must be documented in the patient’s medical record.

Revenue Code 560 "Clinical Social Services", has been deleted from the list of acceptable revenue codes. These charges are reported under one of the remaining revenue codes based on the nature of the service provided.

The professional services listed on page 2 when provided in a hospital outpatient department are separately covered and paid as the professional services of physicians and independent practitioners. These direct professional services are unbundled and these practitioners bill the Medicare Part B Carrier directly for the professional services furnished to hospital outpatient partial hospitalization patients. The hospital can also serve as a billing agent for these professionals by billing the Part B Carrier on their behalf for their professional services.

The process of assigning the proper revenue and procedural codes must accurately reflect the provision of billed services. Psychotherapy codes should not be used as generic psychiatric service codes when another code would be more appropriate. For example, activities related to life skills training, community integration, recreation and monitoring activities of daily living should not be billed with revenue and procedural codes for individual or group psychotherapy. Instead, these services should be properly identified with revenue and procedural codes indicating activity therapy or education and training. Revenue and procedural codes for individual, group and family psychotherapy are exclusively limited to those services provided by physicians, clinical psychologists, licensed clinical social workers, clinical nurse specialists, licensed professional counselors and licensed marriage and family therapists or other individuals licensed or otherwise authorized by the state to perform these services. All services performed by persons not licensed by the state to provide psychotherapy should be designated with other revenue and procedural codes. The facility is also responsible for the proper identification of non-covered services when submitting claims.

Facilities are required to submit hospital outpatient claims on a monthly basis. Once claims are received for payment by the Fiscal Intermediary, the facilities are instructed to make no further adjustments. Once records have been requested, claims cannot be altered in any way during the review process.

90801

Psy dx interview

90802

Intac psy dx interview

90804

Psytx, office, 20-30 min

90805

Psytx, off, 20-30 min w/e&m

90806

Psytx, off, 45-50 min

90807

Psytx, off, 45-50 min w/e&m

90808

Psytx, office, 75-80 min

90809

Psytx, off, 75-80, w/e&m

90810

Intac psytx, off, 20-30 min

90811

Intac psytx, 20-30, w/e&m

90812

Intac psytx, off, 45-50 min

90813

Intac psytx, 45-50 min w/e&m

90814

Intac psytx, off, 75-80 min

90815

Intac psytx, 75-80 w/e&m

90846

Family psytx w/o patient

90847

Family psytx w/patient

90849

Multiple family group psytx

90853

Group psychotherapy

90857

Intac group psytx

90862

Medication management

90865

Narcosynthesis

90870

Electroconvulsive therapy

90899

Psychiatric service/therapy

96105

Assessment of aphasia

96110

Developmental test, lim

96111

Developmental test, extend

97532

Cognitive skills development

97533

Sensory integration

 

 

ICD-9 Codes that Support Medical Necessity 

Inclusive

290.0 - 319

SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED MENTAL RETARDATION

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

1. An admission note stating why the patient is in the outpatient program and the goals to be achieved, including all pertinent past medical and psychiatric history.

2. Psychiatric Assessment (or update or recent workup done within last 90 days) completed and in the medical record within 24 hours of admission.

3. A copy of a history and physical examination completed during the last 30 days and any other pertinent data should be included in the Outpatient medical records with an appropriate medical update. In the absence of a recent history and physical examination, a general health statement by the attending psychiatrist or patient's medical doctor will suffice.

4. Physician progress notes


1. The note must be legible and indicate involvement

2. The progress notes should include documentation of medication management if applicable.



5. Individual treatment plan prescribed and signed by the physician, which identifies treatment goals, describes a coordination of services, is structured to need the particular needs of the patient and includes a multidisciplinary team approach to patient care. The treatment goals should directly address the presenting symptoms and are the basis for evaluating the patient's response to treatment. The treatment plan should document ongoing efforts to restore the patient to a higher level of functioning that would permit discharge from the program, or reflect the need for continued services.

6. Group Notes

There is to be a separate note for each group the patient attends (Social Security Act, Section 1883

Each note is to have:


1. Name of group and the topic discussed as it relates to that individual and the treatment goal being addressed.

2. The date, beginning and ending time of each group.

3. Description of the behaviors and the level of participation exhibited by the patient.


Reflect the patient’s specific problems, but not be limited to:


1. A brief summary of the process, teaching, or activity therapy that occurred in the group;

2. Identification of what was processed, learned, and/or performed by the patient;

3. Identification of how the services are benefiting the patient;

4. Identification of how the patient responded to treatment.

5. If applicable, the patients' involvement in AA/NA with the sponsorship and the results of random UDS performed.

 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:

Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Ruling No. 97-1

CIA 35-14

CMS Pub 100-2, 6§20.4 & 6-§70

A3 3185

A3 3920

Law 18 1866

OPT 405

LMRP 031-96

Outpatient Prospective Payment System, May/June 2000

Outpatient Code Editor

HCFA Hospital Manual HIM 10, 230.4 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

07/12/2000 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

08/28/2000 

 

Revision History Number 

L1372a 

 

Revision History Explanation 

08/02/2004 Crosswalked reference to Online Manual

08/13/2002 Correction of significant coding error

02/22/2001 Updated ICD-9 codes and CPT codes to reflect 2001 code books

11/07/2004 - The description for CPT/HCPCS code 96111 was changed in group 1

09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update.

11/26/2005 - The description for CPT/HCPCS code 90870 was changed in group 1

11/26/2005 - CPT/HCPCS code 90871 was deleted from group 1
11/26/2005 - CPT/HCPCS code 96100 was deleted from group 1
11/26/2005 - CPT/HCPCS code 96115 was deleted from group 1
11/26/2005 - CPT/HCPCS code 96117 was deleted from group 1

This LCD was converted from an LMRP on 12/8/2005

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

09/17/2007 - Frequently Asked Questions restored to Appendices.

11/10/2007 - The description for CPT/HCPCS code 97532 was changed in group 1 

 

Reason for Change 

ICD9 Addition/Deletion
 

Last Reviewed On Date 

12/12/2007 

 

Related Documents 

Article(s)
A37938 - Psychiatric Services-Outpatient Hospital based

 

LCD Attachments 

FAQ - Comment and Response (2,583 bytes)

 

Other Versions 

Updated on 11/10/2007 with effective dates 12/09/2005 - N/A

Updated on 09/17/2007 with effective dates 12/09/2005 - N/A

Updated on 09/01/2006 with effective dates 12/09/2005 - N/A

Updated on 12/15/2005 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 11/07/2004 - 12/08/2005

Updated on 11/07/2004 with effective dates 08/13/2002 - 11/06/2004

Updated on 09/04/2004 with effective dates 08/13/2002 - N/A

Updated on 08/02/2004 with effective dates 08/13/2002 - N/A

Updated on 10/09/2003 with effective dates 08/13/2002 - N/A

Updated on 03/11/2003 with effective dates 08/13/2002 - N/A

Updated on 02/15/2003 with effective dates 08/13/2002 - N/A

Updated on 12/18/2002 with effective dates 08/13/2002 - N/A

Updated on 10/21/2002 with effective dates 08/13/2002 - N/A

Updated on 10/04/2002 with effective dates 08/13/2002 - N/A