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Psychiatry and
Psychology are specialized fields for the diagnosis and treatment of
various mental health disorders and/or diseases.
Information in this part of the policy had been divided into six (6)
sections. These sections address each individual CPT/HCPCS procedure code.
I. General Clinical Psychiatric Diagnostic or Evaluative Interview
Procedures
II. Special Clinical Psychiatric Diagnostic or Evaluative Procedures
III. Psychiatric Therapeutic Services
IV. Psychiatric Somatotherapy
V. Other Psychiatric Disorders
VI. Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental
Status, Speech Testing)
Section I: General Clinical Psychiatric Diagnostic or Evaluative
Interview Procedures:
Description: Procedure 90801 is described as the elicitation of a
complete medical (including past, family, social) and psychiatric history,
establishment of tentative diagnosis, and an evaluation of the patient’s
ability and willingness to work to solve the patient’s mental problem. It
includes a complete mental status exam. Information may be obtained from
the patient, other physicians and/or family. There may be overlapping of
the medical and psychiatric history depending on the problem. An evaluation
and management (E&M) service may be substituted for the initial
interview procedure, including consultation codes (CPT99241-99263),
provided required elements of the E&M service billed are fulfilled.
Consultation services require, in addition to the interview and
examination, providing a written opinion and/or advice. They do not include
psychiatric treatment.
Documentation: The medical record must reflect the elements outlined
in the above description.
Comments: This service may be covered once, at the onset of an
illness or suspected illness. It may be utilized again for the same patient
after a hiatus, or on admission, or re-admission, to inpatient status due
to complications of the underlying condition.
Section II: Special Clinical Psychiatric Diagnostic or Evaluative
Interview examination
Description: Procedure 90802 is described as being used principally
by child psychiatrists, psychologists and clinical social workers when they
initially evaluate children who do not have the ability to interact with
ordinary verbal communication. This code may also be applied to the initial
evaluation of adult patients with organic mental deficits, or who are
catatonic or mute.
The CPT Assistant states that the Interactive Medical Psychiatric
Diagnostic Interview Examination (90802) includes the same components as
the Psychiatric Diagnosis Interview Examination which includes history,
mental status, disposition, and other components as indicated. However, in
the interactive examination, the physician uses inanimate objects, such as
toys and dolls for a child or an interpreter for a deaf person or one who
does no speak English.
Documentation: The medical record must indicate that the person
being evaluated does not have the ability to interact through normal verbal
communicative channels. If the patient is capable of communication by any
means this code may not be billed.
Comments: Procedure code 90802 is covered for the interactive
evaluations of children who are 16 years of age or younger, and of adults,
who have one of the following conditions, as classified in the ICD-9-CM
(2005):
295.21-295.24 Schizophrenic disorders; catatonic type
299.00 Psychoses with origin specific to childhood; infantile autism,
current or active state
299.80 Psychoses with origin specific to childhood; other specified
childhood psychoses ; current or active state
Other catatonic states may be covered if documentation is submitted with
the claim. Coverage also includes interactive examinations of patients with
primary psychiatric diagnosis (e.g., Axis I DSM-III-R or DSM IV diagnoses),
excluding the dementias (ICD-9-CM codes 290.0-290.9) and one of the
following conditions, as classified in the ICD-9-CM (2005):
315.31 Development speech or language disorder
315.39 Developmental speech or language disorder, other
389.00-389.08 Conductive hearing loss, unspecified/combined types
389.10-389.18 Sensorineural hearing loss, unspecified/combined types
389.2 Mixed conductive and sensorineural hearing loss
389.7 Deaf mutism, not elsewhere classifiable
784.3 Aphasia
784.41 Voice disturbance, aphonia
784.5 Other speech disturbance
For the latter group of diagnoses, both the primary and secondary diagnoses
must be submitted with the claim.
Section III: Psychiatric Therapeutic Procedures
Description: Procedure code 90865 is used for the administrative of
sedative or tranquilizer, using intravenously, to relax the patient and
remove inhibitions for discussion of subjects difficult for the patient to
discuss freely in the fully conscious state.
Documentation: The medical records should document the medical
necessity of this procedure, i.e., the patient had difficulty verbalizing
about psychiatric problems without the aide of the drug. The record should
also document the specific pharmacological agent dosage administered, and
whether the technique was effective or non-effective.
Description: Procedure 90804 through 90809 (Psychotherapy) is
defined as "the treatment for mental illness and behavior disturbances
in which the physician establishes a professional contract with the patient
and through definitive therapeutic communication, attempts to alleviate the
emotional disturbances, reverse or change maladaptive patterns of behavior
and encourage personality growth and development."
Documentation: The medical records must indicate the time spent in
the psychotherapy encounter and that, cognitive skills, such as behavior
modification, supportive interactions, and discussion of reality were
applied to produce therapeutic change.
Comments: While a variety of psychotherapeutic techniques are
recognized for coverage under these codes, the services must be performed
by a person licensed by the state to perform psychotherapy services.
Medicare coverage of procedure codes 90804-90809 does not include teaching
grooming skills, monitoring activities of daily living, recreational
therapy (dance, art, play) or social interaction, therefore procedure codes
90804-90809 should not be used to bill for ADL training and/or social
interaction skills.
*Note: Procedure codes 90805, 90807, and 90809 include drug management and
continuing medical diagnostic evaluation as well as psychotherapy.
Therefore, drug management and continuing diagnostic evaluation may not be
billed separately on the same day.
Guidelines for Procedure Codes 90804-90809
1. Individual psychotherapy codes should be used only when the focus of
treatment involves individual therapy and/or continuing medical diagnostic
evaluation. Psychotherapy codes should not be used as generic psychiatric
service codes when another code, such as E&M or pharmacologic
management code, would be more appropriate.
2. Prolonged treatment (in excess of twenty sessions per episode of illness)
may be subject to medical review. Documentation must be present in the
medical record indicating the necessity for continued treatments.
4. Procedure codes 90808/90809 (approximately 75-80 minutes) should not be
routinely used. They are reserved for exceptional circumstances. The
provider of service must document in the patient’s medical record the
medical necessity of this service and define the exceptional circumstances.
5. Medicare will not accept psychiatric therapy procedure codes 90804-90809
being billed on the same date of service as an evaluation and management
(E&M) service, by the same provider or mental health profession group.
The single exception is that a consultation may be billed at the initial
visit and psychotherapy may be billed on the same date of service, if it is
medically indicated.
6. Psychotherapy services are not covered when documentation indicates that
Dementia (ICD-9 codes, 290.0, 290.20-290.9, 331.0-331.2) has produced a
severe enough cognitive defect to prevent establishment of a relationship
with the therapist which would allow insight-oriented therapy to be
effective. Profound mental retardation (ICD-9 code 318.2) is never covered
for psychotherapy services. In such cases, evaluation and management codes
or pharmacologic management codes should be reported.
7. For psychotherapy sessions lasting longer than 90 minutes (or if an
additional code is billed in conjunction with codes 90808/90809),
reimbursement will only be made if a report is submitted with the claim, documenting
the face-to-face time spent with the patient and the medical necessity for
the extended time.
Description: Procedure code 90845 is the practice of psychoanalysis
which uses a special technique to gain insight into a patient’s unconscious
motivations and conflicts and is a different therapeutic modality than
psychotherapy.
Documentation: The medical record must indicate that psychoanalytic
techniques were used.
Comments: The physician using this technique must be trained and
credentialed in its use. It is not time related, but the code is billed
once for each daily session regardless of the time involved. The Relative
Value Units assigned to this code are based on a 45-60 minute session.
Psychoanalysis is generally considered unsuitable for psychoses.
Medicare coverage includes the following diagnosis codes:
296.20-296.25
Major depressive disorders, single episodes ; unspecified to in partial or
unspecified remission
296.30-296.35
Major depressive disorders, recurrent episodes; unspecified to in partial
or unspecified remission
300.01 Panic disorder
300.02 Generalized anxiety disorder
300.20-300.29 Phobias, unspecified to other isolated or simple phobias
300.3 Obsessive-compulsive disorder
300.4 Neurotic depression
309.1 Prolonged depressive reaction
309.21 Separation anxiety disorder
309.22
Emancipation disorder of adolescence or early adult life
309.23 Specific academic or work inhibition
Description: Procedure codes 90846, 90847, 90849 are used to
describe family participation in the treatment process of the patient. Code
90846 is used when the patient is not present. Code 90847 is used when the
patient is present. Code 90849 is intended for group therapy sessions for
multiple families when similar dynamics are occurring due to a commonality
of problems in the family members under treatment.
Documentation: The medical record must document the conditions
described under Description and Comments paragraphs relative to codes
90846, 90847, and 90849.
Comments: The Medicare National Coverage Determination Manual,
1.1.§70.1 states that family counseling services are covered only where the
primary purpose of such counseling is the treatment of the patient’s
condition. Examples are as follows:
1. When there is a need to observe the patient’s interaction with family
members (CPT 90847).
2. Where there is a need to assess the capability of, and assist the family
members in, the management of the patient (90846 or 90847).
3. These codes may also apply when the patient is comatose or withdrawn and
uncommunicative due to a mental disorder.
Code 90849 has restrictive coverage by Medicare and would generally be
non-covered. Such group therapy is directed to the effects of the patients’
condition on the family, and does not meet Medicare’s standards of being
part of the physician's personal services to the patient. If such is not
the case, individual consideration may be given if documentation is
submitted.
Description: Psychotherapy administered in a group setting (90853)
with a trained group leader in charge of several patients. Personal and
group dynamics are discussed and explored in a therapeutic setting allowing
emotional catharsis, instruction and support.
Documentation: The record must indicate that the guidelines under
Description and Comments were followed.
Comments: Group therapy, since it involves psychotherapy, must be
led by a person who is authorized by state statute to perform this service.
This will usually mean a psychiatrist, psychologist, or clinical social
worker and, in some states, certified nurse practitioners, clinical nurse
specialists, or qualified mental health personnel. For Medicare Part B
coverage, group therapy does not include socialization, music therapy,
recreational activities, art classes, excursions, sensory stimulation or
eating together, cognitive stimulation, motion therapy, etc.
Description: As with code 90802, and 90857 are used when the
patient, or patients in the group setting, does not have the ability to
interact by ordinary verbal communication therefore non-verbal
communication skills are employed, or an interpreter may be necessary. Code
90855 is comparable in time to 90806/90807 (45-50 minutes). The guidelines
in the Documentation section under CPT 90802 apply to code 90857.
Documentation: Documentation in the medical record must include the
need for interactive therapy. The guidelines in the Documentation section
under code 90802 apply to code 90847.
Comments: Code 90857 should not be billed on the same date of
service as 90853.
Section IV: Psychiatric Somatotherapy
Description: Code 90862 is intended for use by the physician who is
prescribing pharmacologic therapy for a patient with an organic brain
syndrome or whose diagnosis is in the ICD-9 range of 290.0-319, and is
being managed primarily by psychotropic drugs. It may also be used for the
patient whose psychotherapy is being managed by another health professional
and the billing physician is managing the psychotropic medication. The
service includes prescribing, monitoring the effect of medication and
adjusting the dosage. Any psychotherapy provided is minimal and is usually
supportive only.
Documentation: The record must document that the guidelines under
Description and Comments are followed.
Comments: If the physician supplies other services in addition to
pharmacologic management at the visit then an E&M code may be used.
However, the E&M service will include pharmacologic management and
therefore 90862 should not be billed in addition to the E&M service.
Based on physician work relative value units, the physician work component
of the code is similar to Code 99214 (equivalent to 25-30 minutes).
If the patient receives psychotherapy and drug management at the same
visit, the drug management is included, as part of that service by
definition and 90862 should not be billed in addition to the psychotherapy
code.
This code is not intended to be used for the actual administration of
medication, nor is it intended to be used for observation of the patient
taking an oral medication. Administration and supply of oral medication is
a non-covered service.
Codes 90862 and M0064 describe a physician service and cannot be billed by
a non-physician’s service, with the exception that nurse practitioners
whose scope of license in their states permit them to prescribe may use
this code if they perform these services.
Code 90862 is not intended to refer to a brief evaluation of the patient's
state or simple dosage adjustment of long term medication. The code refers
to the in-depth management of psychopharmacologic agents, which are potent
medications with frequent serious side effects, and represents a very
skilled aspect of patient care.
HCPCS' code M0064 should be used for the lesser level of drug monitoring
such as simple dosage adjustment. M0064 is defined as a brief office visit
for the sole purpose of monitoring or changing drug prescriptions used in
the treatment of mental, psychoneurotic and personality disorders. Based on
the assignment of RVUs, the work involved in M0064 is similar to code
99212. Time spent is generally less than ten minutes'
Medicare covers the following diagnosis codes for codes 90862 or M0064:
290.0-305.00 Senile dementia, uncomplicated to alcohol abuse, unspecified
305.20-319 Nondependent abuse of drugs; cannabis abuse, unspecified to
unspecified mental retardation
Description: Codes 90870 and 90871 are described as the application
of electric current to the brain, through scalp electrodes to produce a
single (90870) or multiple (90871) seizures.
Documentation and Comment: When the psychiatrist administers the
anesthesia for the seizure therapy, no separate payment may be made for
that service.
Section V: Other Psychiatric Therapy
Description: Code 90880 is described as medical hypnotherapy.
Hypnotherapy is an artificially induced alteration of consciousness in
which the patient is in a state of increased suggestibility.
Documentation: Claims must be submitted with a covered diagnosis.
Comments: Hypnosis may be used for diagnostic or therapeutic purposes.
When used therapeutically to enhance psychotherapy or provided in
conjunction with psychotherapy in the same session, only code 90880 should
be reported.
Medicare will cover hypnotherapy for the following diagnoses:
300.11 Conversion disorders
300.12 Psychogenic amnesia
300.13 Psychogenic fugue
300.14 Multiple personality
300.15 Dissociative disorder or reaction, unspecified
300.20-300.29 Phobias, unspecified to other isolated or simple phobias
307.80 Psychogenic pain, site unspecified
308.0-309.9 Predominant disturbance of emotions to unspecified adjustment
reaction
Code 90882, environmental intervention for medical management purposes on a
psychiatric patient’s behalf with agencies, employers, or institutions is
NON COVERED by Medicare.
Description: Code 90889 involves preparation of reports for
insurance companies, agencies, courts, etc. Medicare does not cover this
service.
Section VI: Central Nervous System Assessments/Tests (e.g.,
Neuro-Cognitive, Mental Status, Speech Testing)
Description: Code 96101, 96102, 96103 includes the administration,
interpretation and scoring of the tests mentioned in the CPT description
and other medically accepted tests for evaluation of intellectual
strengths, psychopathology, psychodynamics, mental health risks, insight,
motivation and other factor influencing treatment and prognosis.
Documentation: The medical record must indicate the presence of
mental illness or signs of mental illness for which psychological testing
is indicated as an aid in the diagnosis and therapeutic planning. The
record must show the tests performed, scoring and interpretation, as well
as the time involved.
Comments: These are not psychotherapeutic modalities, but are
diagnosis aids, Use of such tests when mental illness is not suspected
would be a screening procedure and is not covered by Medicare. Each test
performed must be medically necessary and therefore standardized batteries
of tests are not acceptable. The Folstein Mini-Mental Exam (or similar
test) is not separately reimbursable by Medicare and is included in the
clinical interview or E&M service.
Changes in mental illness may require psychological testing to determine
new diagnoses of the need for changes in therapeutic measure. Repeat
testing not required for a diagnosis or continued treatment would be
considered medically unnecessary. Nonspecific behaviors, which do not
indicate the presence of, or change n, a mental illness would not be an
acceptable indication for testing. psychological or psychiatric evaluations
that can be accomplished through the clinical interview alone (e.g.,
response to medication) would not require psychological testing, and such
testing might be considered as medically unnecessary. Adjustment reactions
or dysphoria associated with moving to a nursing facility do not constitute
medical necessity for psychological testing.
Code 96101 should not be reported by the treating psychiatrist for reading
the report of the results of psychological testing by the psychiatrist and
the reading of the report is therefore included in the office, or floor
time in the hospital, for that day, and would be included in the E&N
service code for that day.
Description: Codes 96101,96102, 96103, 96105, 96110, 96111, and 96116
are clearly delineated in the CPT definition. Codes 96118, 96119, 96120
describe testing which is intended to describe and diagnose the
neurocognitive effects of medical disorders that impinge directly or
indirectly on the brain. Examples of problems, which might lead to
neuropsychological testing, are:
1. Detection of neurologic diseases based on quantitative assessment of
neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS
dementia)
2. Differential diagnosis between psychogenic and neurogenic syndromes
(e.g., depression vs. dementia)
3. Delineation of the neurocognitive effects of CNS disorders
4. Neurocognitive monitoring of recovery or progression of CNS disorders;
and
5. Assessment of neurocognitive functions for the formulation of
rehabilitation and/or management strategies among individuals with
neurologic disorders.
Documentation: The medical record must document that the guidelines
outlined in the Description and Comments were followed.
Comments (96118, 96119, 96120): The content of Neuropsychological
Testing procedures differs in a large part from that of Psychological
Testing (96101 96102, 96103) in that Neuropsychological testing consists
primarily of individually administered ability tests that comprehensively
sample ability domains that are known to be sensitive to the functional
integrity of the brain (e.g., abstraction, memory and learning, attention,
language, problem solving, sensorimotor functions, constructional praxis,
etc.). These procedures are objective and quantitative in nature and
require that patient to directly demonstrate their level of competence in a
particular cognitive domain. Neuropsychological Testing does not rely on
self-report questionnaires such as the Minnesota Multiphasic Personality
Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating
Scale, or projective techniques such as the Rorschach or Thematic
Appreciation Test (TAT). These procedures are intended for psychological
testing and should be covered under 96110. Brief screening measures such as
the Folstein Mini Mental Status Exam or use of other mental status exams in
isolation should not be classified separately as Neuropsychological Testing
(96118, 96119, 96120) since they are typically part of a more general
clinical exam or interview.
Typically, the test battery will require from 5-7 hours to perform,
including administration, scoring and interpretation. If the testing is
done over several days, the testing time should be combined and reported
all on the last date of service. If the testing time exceeds 11 hours, a
report must be submitted indicating the medical necessity for this extended
testing.
Indications: Neuropsychological conditions, which fall under the
Descriptions and Comments sections preceeding. ICD-9 codes which are
descriptive of those conditions will be covered for code 96118, 96119,
96120.
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