Outpatient Psychiatric Services

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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L14395

LCD Title

Outpatient Psychiatric Services

Contractor’s Policy Number

04-01-R1

AMA CPT Copyright Statement

CMS National Coverage Policy

Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Medicare Intermediary Manual, section 3112 (7)(B)(3), describes outpatient hospital psychiatric services.
Medicare Hospital Manual, section 230.4, describes coverage of outpatient therapeutic services.
Medicare Hospital Manual, section 230.5, describes outpatient hospital psychiatric services.
Medicare Coverage Issues Manual, section 35-14, describes coverage of consultations with a beneficiary's family and associates.
Medicare Coverage Issues Manual, section 35-22, describes coverage of outpatient hospital services for the treatment of alcoholism.
Medicare Coverage Issues Manual, section 35-23, describes coverage of chemical aversion therapy for the treatment of alcoholism.
Medicare Coverage Issues Manual, section 80-1, describes coverage of patient education programs
Program Memorandum, AB-03-037, CR 2520, Provider Education Article: Medicare Payments for Part B Mental Health Services
Program Memorandum, A-01-111, CR 1798, Clarification of HCPC G0177.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

12/29/2003

Original Policy Ending Date

Revision Effective Date

10/01/2004

Revision Ending Date

09/30/2004

LMRP Description

Outpatient psychiatric services represent a variety of ambulatory psychiatric services used to provide active treatment to individuals with mental disorders. Other than certain diagnostic tests, these services are provided incident to the services of a psychiatrist or other physician (M.D. or D.O.) trained in the treatment of psychiatric disorders.

This policy does not address Partial Hospitalization Programs.

Indications and Limitations of Coverage and/or Medical Necessity

Outpatient psychiatric services can be billed incident to a physician's services provided the following conditions are met:

The physician has performed an initial evaluation.
A written plan of treatment has been developed which the physician has approved.
The physician has an active and continuous role in the management of the patient including clinical supervision of all those involved in providing psychiatric services to the patient.
The physician's ongoing involvement is documented in the patient record.
Non-physician practitioners are licensed and authorized by the state to perform the services they provide.
Non-physician practitioners are hospital employees.
The patient is an outpatient.
The services are not received in the home setting.
The patient (or legal guardian) has provided written, informed consent for treatment.
The patient's assessment indicates that the patient has a reasonable expectation of improvement as a result of the treatment provided.
The patient is able to participate in a meaningful way in the services provided.
All services are to be comprised of clinically recognized interventions, which are pertinent to the patient's illness or condition, which may include: individual psychotherapy; group psychotherapy; family counseling; occupational therapies; and, psycho-educational groups.

A treatment plan that establishes a course of therapy comprised primarily of activity, social, or recreational therapy does not constitute medically necessary psychiatric services. Psychosocial programs or services, which provide only a structured environment, socialization, and/or vocational rehabilitation, are not covered by Medicare.

A course of therapy need not have as its goal restoration of the patient's premorbid status. For many psychiatric patients (particularly those with long-term, chronic conditions) control of symptoms to avoid further deterioration and to maintain a reasonable functional level and avoid hospitalization is an acceptable goal. Improvement in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Services should be provided at the lowest level of intensity required to achieve and maintain this improvement.

Covered Services:

Medically necessary diagnostic services related to mental illness
Individual and group psychotherapy

This service must be provided by physicians, psychologists, and other mental health professionals licensed or authorized by the state to perform such a service. The license or authorization must specify that the practitioner's scope of practice includes psychotherapy for the treatment of mental illness.

Occupational therapy

These services must be provided by a qualified occupational therapist.
These services must be included in the individualized treatment plan developed by the physician.
Such services may include pre-vocational assessment and training, but services related to specific employment opportunities are not covered.

Other psychiatric services

Services of staff trained to work with psychiatric patients. (Individual and group psychotherapy must only be performed by mental health professionals licensed or authorized by the state to perform such a service.)

Drugs and biologicals

This includes medications that are usually not self-administered.

Family counseling

These services must be provided by a mental health professional licensed or authorized by the state to perform such a service.
These services must be for the primary purpose of treating the patient's condition. They may include observing and assessing the patient's interaction with family members; counseling the family to assist in the patient's management; attempting to modify the behavior of family members when necessary to facilitate the patient's improvement. When this service is provided without the patient present, the counseling should still relate directly to the patient.

Individualized activity therapies

These services must be included in the individualized treatment plan developed by the physician.
The need for these services as a treatment of the patient's condition must be clearly documented.
These therapies should not be billed as individual or group psychotherapies.

Patient training and education

These services should be clearly related to the individual's care and treatment of their diagnosed psychiatric condition

CPT/HCPCS Section & Benefit Category

Psychiatry

Type of Bill Code

13X, 76X

Revenue Codes

250, 43X, 513, 900, 901, 904, 914, 915, 916, 918, 942, 944, 945

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

90801	Ó	Psy dx interview
90802	Ó	Interactive psy dx interview
90804	Ó	Indiv psy, outpt, 20-30 min
90805	Ó	Indiv psy; outpt, 20-30 min w/e&m
90806	Ó	Indiv psy, outpt, 45-50 min
90807	Ó	Indiv psy, outpt, 45-50, w/e&m
90808	Ó	Indiv psy, outpt, 75-80 min
90809	Ó	Indiv psy, outpt, 75-80 min w/e&m
90810	Ó	Intac psy, outpt, 20-30 min
90812	Ó	Intac psy, 45-50 min
90814	Ó	Intac psy 75-80 min
90845	Ó	Psychoanalysis
90846	Ó	Family therapy w/o patient
90847	Ó	Family therapy w/patient
90853	Ó	Group therapy
90857	Ó	Intac group therapy
90862	Ó	Pharmacologic therapy
90865	Ó	Narcosynthesis
90870	Ó	ECT; single seizure
90880	Ó	Hypnotherapy
90887	Ó	Interpretation or explanation to family
96100	Ó	Psychological testing
96110	Ó	Developmental test, ltd
96111	Ó	Developmental test, extend
96115	Ó	Neurobehavioral status exam
96117	Ó	Neuropsych test battery
97003	Ó	OT evaluation
97004	Ó	OT re-evaluation
97530	Ó	Therapeutic activities
97532	Ó	Development of cognitive skills
97533	Ó	Sensory integrative techniques
97535	Ó	Self-care/home mngment trng
97537	Ó	Community/work reintegration trng
G0177		Trng and educational svcs

Ó CPT American Medical Association

Not Otherwise Classified (NOC)

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Medicare is establishing the following limited coverage:

Covered for:

290.0		Senile dementia, uncomplicated
290.10		Presenile dementia, uncomplicated
290.11		Presenile dementia with delirium
290.12		Presenile dementia with delusional features
290.13		Presenile dementia with depressive features
291.1		Alcohol-induced persisting amnestic disorder
291.2		Alcohol-induced persisting dementia
291.3		Alcohol-induced psychotic disorder with hallucinations
291.5		Alcohol-induced psychotic disorder with delusions
291.81		Other specified alcohol-induced mental disorders
291.89		Other specified alcoholic psychosis, other
291.9		Unspecified alcohol-induced mental disorders
292.0		Drug withdrawal
292.11		Drug-induced psychotic disorder with delusions
292.12		Drug-induced psychotic disorder with hallucinations
292.81		Other specified drug-induced mental disorders, drug induced delirium
292.82		Drug-induced persisting dementia
292.83		Drug-induced persisting amnestic disorder
292.84		Drug-induced mood disorder
292.89		Other specified drug-induced mental disorders, other
292.9		Unspecified drug-induced mental disorder
293.81		Psychotic disorder with delusions in conditions classified elsewhere
293.82		Psychotic disorder with hallucinations in conditions classified elsewhere
293.83		Mood disorder in conditions classified elsewhere
293.84		Anxiety disorder in conditions classified elsewhere
293.89		Other
293.9		Unspecified transient mental disorder in conditions classified elsewhere
294.0		Amnestic syndrome
294.10		Dementia in conditions classified elsewhere without behavioral disturbance
294.11		Dementia in conditions classified elsewhere with behavioral disturbance
294.8		Other specified organic brain syndromes (chronic)
294.9		Unspecified organic brain syndrome (chronic)
295.00		Schizophrenic disorder, simple type, unspecified
295.01		Schizophrenic disorder, simple type, subchronic
295.02		Schizophrenic disorder, simple type, chronic
295.03		Schizophrenic disorder, simple type, subchronic with acute exacerbation
295.04		Schizophrenic disorder, simple type, chronic with acute exacerbation
295.05		Schizophrenic disorder, simple type, in remission
295.10		Schizophrenic disorder, disorganized type, unspecified
295.11		Schizophrenic disorder, disorganized type, subchronic
295.12		Schizophrenic disorder, disorganized type, chronic
295.13		Schizophrenic disorder, disorganized type, subchronic with acute exacerbation
295.14		Schizophrenic disorder, disorganized type, chronic with acute exacerbation
295.15		Schizophrenic disorder, disorganized type, in remission
295.20		Schizophrenic disorder, catatonic type, unspecified
295.21		Schizophrenic disorder, catatonic type, subchronic
295.22		Schizophrenic disorder, catatonic type, chronic
295.23		Schizophrenic disorder, catatonic type, subchronic with acute exacerbation
295.24		Schizophrenic disorder, catatonic type, chronic with acute exacerbation
295.25		Schizophrenic disorder, catatonic type, in remission
295.30		Schizophrenic disorder, paranoid type, unspecified
295.31		Schizophrenic disorder, paranoid type, subchronic
295.32		Schizophrenic disorder, paranoid type, chronic
295.33		Schizophrenic disorder, paranoid type, subchronic with acute exacerbation
295.34		Schizophrenic disorder, paranoid type, chronic with acute exacerbation
295.35		Schizophrenic disorder, paranoid type, in remission
295.40		Schizophreniform disorder, unspecified
295.41		Schizophreniform disorder, subchronic
295.42		Schizophreniform disorder, chronic
295.43		Schizophreniform disorder, subchronic with acute exacerbation
295.44		Schizophreniform disorder, chronic with acute exacerbation
295.45		Schizophreniform disorder, in remission
295.50		Latent schizophrenia, unspecified
295.51		Latent schizophrenia, subchronic
295.52		Latent schizophrenia, chronic
295.53		Latent schizophrenia, subchronic with acute exacerbation
295.54		Latent schizophrenia, chronic with acute exacerbation
295.55		Latent schizophrenia, in remission
295.60		Schizophrenic disorders, residual type, unspecified
295.61		Schizophrenic disorders, residual type, subchronic
295.62		Schizophrenic disorders, residual type, chronic
295.63		Schizophrenic disorders, residual type, subchronic with acute exacerbation
295.64		Schizophrenic disorders, residual type, chronic with acute exacerbation
295.65		Schizophrenic disorders, residual type, in remission
295.70		Schizoaffective disorder, unspecified
295.71		Schizoaffective disorder, subchronic
295.72		Schizoaffective disorder, chronic
295.73		Schizoaffective disorder, subchronic with acute exacerbation
295.74		Schizoaffective disorder, chronic with acute exacerbation
295.75		Schizoaffective disorder, in remission
295.80		Other specified types of schizophrenia, unspecified
295.81		Other specified types of schizophrenia, subchronic
295.82		Other specified types of schizophrenia, chronic
295.83		Other specified types of schizophrenia, subchronic with acute exacerbation
295.84		Other specified types of schizophrenia, chronic with acute exacerbation
295.85		Other specified types of schizophrenia, in remission
295.90		Unspecified schizophrenia, unspecified
295.91		Unspecified schizophrenia, subchronic
295.92		Unspecified schizophrenia, chronic
295.93		Unspecified schizophrenia, subchronic with acute exacerbation
295.94		Unspecified schizophrenia, chronic with acute exacerbation
295.95		Unspecified schizophrenia, in remission
296.00		Bipolar I disorder, single manic episode, unspecified
296.01		Bipolar I disorder, single manic episode, mild
296.02		Bipolar I disorder, single manic episode, moderate
296.03		Bipolar I disorder, single manic episode, severe, without mention
		of psychotic behavior
296.04		Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior
296.05		Bipolar I disorder, single manic episode, in partial or unspecified remission
296.06		Bipolar I disorder, single manic episode, in full remission
296.10		Manic disorder, recurrent episode, unspecified
296.11		Manic disorder, recurrent episode, mild
296.12		Manic disorder, recurrent episode, moderate
296.13		Manic disorder, recurrent episode, severe, without mention of psychotic behavior
296.14		Manic disorder, recurrent episode, severe, specified as with psychotic behavior
296.15		Manic disorder, recurrent episode, in partial or unspecified remission
296.16		Manic disorder, recurrent episode, in full remission
296.20		Major depressive disorder, single episode, unspecified
296.21		Major depressive disorder, single episode, mild
296.22		Major depressive disorder, single episode, moderate
296.23		Major depressive disorder, single episode, severe, without mention
		of psychotic behavior
296.24		Major depressive disorder, single episode, severe, specified as
		with psychotic behavior
296.25		Major depressive disorder, single episode, in partial or unspecified remission
296.26		Major depressive disorder, single episode, in full remission
296.30		Major depressive disorder, recurrent episode, unspecified
296.31		Major depressive disorder, recurrent episode, mild
296.32		Major depressive disorder, recurrent episode, moderate
296.33		Major depressive disorder, recurrent episode, severe, without
		mention of psychotic behavior
296.34		Major depressive disorder, recurrent episode, severe, specified as
		with psychotic behaviorwith psychotic behavior
296.35		Major depressive disorder, recurrent episode, in partial or unspecified remission
296.36		Major depressive disorder, recurrent episode, in full remission
296.40		Bipolar I disorder, most recent episode (or current) manic, unspecified
296.41		Bipolar I disorder, most recent episode (or current), manic, mild
296.42		Bipolar I disorder, most recent episode (or current), manic, moderate
296.43		Bipolar I disorder, most recent episode (or current), manic, severe, without mention
		of psychotic behavior
296.44		Bipolar I disorder, most recent episode ( or current), manic, severe, specified
		as with psychotic behavior
296.45		Bipolar I disorder, most recent episode ( or current), manic, in partial
		or unspecified remission
296.46		Bipolar I disorder, most recent episode ( or current), manic, in full remission
296.50		Bipolar I disorder, most recent episode (or current) depressed, unspecified
296.51		Bipolar I disorder, most recent episode (or current) depressed, mild
296.52		Bipolar I disorder, most recent episode (or current) depressed, moderate
296.53		Bipolar I disorder, most recent episode (or current) depressed, severe,
		without mention of psychotic behavior
296.54		Bipolar I disorder, most recent episode (or current) depressed, severe,
		specified as with psychotic behavior
296.55		Bipolar I disorder, most recent episode (or current) depressed, in partial or
		unspecified remission
296.56		Bipolar I disorder, most recent episode (or current) depressed, in full remission
296.60		Bipolar I disorder, most recent episode (or current) mixed, unspecified
296.61		Bipolar I disorder, most recent episode (or current) mixed, mild
296.62		Bipolar I disorder, most recent episode (or current) mixed, moderate
296.63		Bipolar I disorder, most recent episode (or current) mixed, severe,
		psychotic behavior without mention of psychotic behavior
296.64		Bipolar I disorder, most recent episode (or current) mixed, severe,
		specified as with psychotic behavior
296.65		Bipolar I disorder, most recent episode (or current) mixed,
		in partial or unspecified remission
296.66		Bipolar I disorder, most recent episode (or current) mixed, in full remission
296.7		Bipolar I disorder, most recent episode (or current) unspecified
296.80		Bipolar disorder, unspecified
296.81		Atypical manic disorder
296.82		Atypical depressive disorder
296.89		Manic-depressive psychosis, other
296.90		Unspecified episodic mood disorder
296.99		Other specified episodic mood disorder
297.0		Paranoid state, simple
297.1		Delusional disorder
297.2		Paraphrenia
297.3		Shared psychotic disorder
297.8		Other specified paranoid states
297.9		Unspecified paranoid state
298.0		Depressive type psychosis
298.1		Excitative type psychosis
298.2		Reactive confusion
298.3		Acute paranoid reaction
298.4		Psychogenic paranoid psychosis
298.8		Other and unspecified reactive psychosis
298.9		Unspecified psychosis
299.10		Childhood disintegrative disorder, active state
299.11		Childhood disintegrative disorder, residual state
299.80		Other specified pervasive developmental disorders, active state
299.81		Other specified pervasive developmental disorders, residual state
299.90		Unspecified pervasive developmental disorder, active state
299.91		Unspecified pervasive developmental disorder, residual state
300.00		Anxiety state, unspecified
300.01		Panic disorder without agoraphobia
300.02		Generalized anxiety disorder
300.09		Anxiety state, other
300.10		Hysteria, unspecified
300.11		Conversion disorder
300.12		Dissociative amnesia
300.13		Dissociative fugue
300.14		Dissociative identity disorder
300.15		Dissociative disorder or reaction, unspecified
300.16		Factitious disorder with predominantly pshycological signs and symptoms
300.19		Other and unspecified factitious illness
300.20		Phobia, unspecified
300.21		Agoraphobia with panic disorder
300.22		Agoraphobia without mention of panic attacks
300.23		Social phobia
300.29		Other isolated or specific phobias
300.3		Obsessive-compulsive disorders
300.4		Dysthymic disorder
300.5		Neurasthenia
300.6		Depersonalization disorder
300.7		Hypochondriasis
300.81		Somatization disorder
300.82		Undifferentiated somatoform disorder
300.89		Other somatoform disorders
300.9		Unspecified nonpsychotic mental disorder
301.0		Paranoid personality disorder
301.10		Affective personality disorder, unspecified
301.11		Chronic hypomanic personality disorder
301.12		Chronic depressive personality disorder
301.13		Cyclothymic disorder
301.20		Schizoid personality disorder, unspecified
301.21		Introverted personality
301.22		Schizotypal personality disorder
301.3		Explosive personality disorder
301.4		Obsessive-compulsive personality disorder
301.50		Histrionic personality disorder, unspecified
301.51		Chronic factitious illness with physical symptoms
301.59		Other histrionic personality disorder
301.6		Dependent personality disorder
301.7		Antisocial personality disorder
301.81		Narcissistic personality disorder
301.82		Avoidant personality disorder
301.83		Borderline personality disorder
301.84		Other personality disorder, Passive-aggressive personality
301.89		Other personality disorder, other
301.9		Unspecified personality disorder
302.0		Ego-dystonic sexual orientation
302.1		Zoophilia
302.2		Pedophilia
302.3		Transvestic fetishism
302.4		Exhibitionism
302.50		Trans-sexualism with unspecified sexual history
302.51		Trans-sexualism with asexual history
302.52		Trans-sexualism with homosexual history
302.53		Trans-sexualism with heterosexual history
302.6		Gender identity disorder in children
302.70		Psychosexual dysfunction, unspecified
302.71		Hypoactive sexual desire disorder
302.72		Psychosexual dysfunction, with inhibited sexual excitement
302.73		Female orgasmic disorder
302.74		Male orgasmic disorder
302.75		Premature ejaculation
302.76		Dyspareunia, psychogenic
302.79		Psychosexual dysfunction, with other specified psychosexual dysfunctions
302.81		Fetishism
302.82		Voyeurism
302.83		Sexual masochism
302.84		Sexual sadism
302.85		Gender identity disorder in adolescents or adults
302.89		Other specified psychosexual disorders, other
302.9		Unspecified psychosexual disorder
303.90		Other and unspecified alcohol dependence, unspecified
303.91		Other and unspecified alcohol dependence, continuous
303.92		Other and unspecified alcohol dependence, episodic
303.93		Other and unspecified alcohol dependence, in remission
304.00		Opioid type dependence, unspecified
304.01		Opioid type dependence, continuous
304.02		Opioid type dependence, episodic
304.03		Opioid type dependence, in remission
304.10		Sedative, hypnotic or anxiolytic dependence, unspecified
304.11		Sedative, hypnotic or anxiolytic dependence, continuous
304.12		Sedative, hypnotic or anxiolytic dependence, episodic
304.13		Sedative, hypnotic or anxiolytic dependence, in remission
304.20		Cocaine dependence, unspecified
304.21		Cocaine dependence, continuous
304.22		Cocaine dependence, episodic
304.23		Cocaine dependence, in remission
304.30		Cannabis dependence, unspecified
304.31		Cannabis dependence, continuous
304.32		Cannabis dependence, episodic
304.33		Cannabis dependence, in remission
304.40		Amphetamine and other psychostimulant dependence, unspecified
304.41		Amphetamine and other psychostimulant dependence, continuous
304.42		Amphetamine and other psychostimulant dependence, episodic
304.43		Amphetamine and other psychostimulant dependence, in remission
304.50		Hallucinogen dependence, unspecified
304.51		Hallucinogen dependence, continuous
304.52		Hallucinogen dependence, episodic
304.53		Hallucinogen dependence, in remission
304.60		Other specified drug dependence, unspecified
304.61		Other specified drug dependence, continuous
304.62		Other specified drug dependence, episodic
304.63		Other specified drug dependence, in remission
304.70		Combinations of opioid type drug with any other, unspecified
304.71		Combinations of opioid type drug with any other, continuous
304.72		Combinations of opioid type drug with any other, episodic
304.73		Combinations of opioid type drug with any other, in remission
304.80		Combinations of drug dependence excluding opioid type drug, unspecified
304.81		Combinations of drug dependence excluding opioid type drug, continuous
304.82		Combinations of drug dependence excluding opioid type drug, episodic
304.83		Combinations of drug dependence excluding opioid type drug, in remission
304.90		Unspecified drug dependence, unspecified
304.91		Unspecified drug dependence, continuous
304.92		Unspecified drug dependence, episodic
304.93		Unspecified drug dependence, in remission
305.00		Alcohol abuse, unspecified
305.01		Alcohol abuse, continuous
305.02		Alcohol abuse, episodic
305.03		Alcohol abuse, in remission
305.20		Cannabis abuse, unspecified
305.21		Cannabis abuse, continuous
305.22		Cannabis abuse, episodic
305.23		Cannabis abuse, in remission
305.30		Hallucinogen abuse, unspecified
305.31		Hallucinogen abuse, continuous
305.32		Hallucinogen abuse, episodic
305.33		Hallucinogen abuse, in remission
305.40		Sedative, hypnotic or anxiolytic abuse, unspecified
305.41		Sedative, hypnotic or anxiolytic abuse, continuous
305.42		Sedative, hypnotic or anxiolytic abuse, episodic
305.43		Sedative, hypnotic or anxiolytic abuse, in remission
305.50		Opioid abuse, unspecified
305.51		Opioid abuse, continuous
305.52		Opioid abuse, episodic
305.53		Opioid abuse, in remission
305.60		Cocaine abuse, unspecified
305.61		Cocaine abuse, continuous
305.62		Cocaine abuse, episodic
305.63		Cocaine abuse, in remission
305.70		Amphetamine or related abuse, unspecified
305.71		Amphetamine or related abuse, continuous
305.72		Amphetamine or related abuse, episodic
305.73		Amphetamine or related abuse, in remission
305.80		Antidepressant type abuse, unspecified
305.81		Antidepressant type abuse, continuous
305.82		Antidepressant type abuse, episodic
305.83		Antidepressant type abuse, in remission
305.90		Other, mixed, or unspecified drug abuse, unspecified
305.91		Other, mixed, or unspecified drug abuse, continuous
305.92		Other, mixed, or unspecified drug abuse, episodic
305.93		Other, mixed, or unspecified drug abuse, in remission
306.51		Psychogenic paganisms
306.52		Psychogenic dysmenorrhea
306.53		Psychogenic dysuria
306.59		Physiologic malfunction from mental factors, genitourinary, other
307.1		Anorexia nervosa
307.20		Tic disorder, unspecified
307.21		Transient tic disorder
307.22		Chronic motor or vocal tic disorder
307.23		Tourette's disorder
307.3		Sterotypic movement disorder
307.42		Persistent disorder of initiating or maintaining sleep
307.44		Persistent disorder of initiating or maintaining wakefulness
307.46		Sleep arousal disorder
307.47		Other dysfunctions of sleep stages or arousal from sleep
307.49		Specific disorders of sleep of nonorganic origin, other
307.50		Eating disorder, unspecified
307.51		Bulimia nervosa
307.52		Pica
307.53		Rumination disorder
307.54		Psychogenic vomiting
307.59		Other disorders of eating
307.6		Enuresis
307.7		Encopresis
307.80		Psychogenic pain, site unspecified
307.89		Psychalgia, other
307.9		Other and unspecified special symptoms or syndromes, not elsewhere classified
308.0		Acute reaction to stress, predominant disturbance of emotions
308.1		Acute reaction to stress, predominant disturbance of consciousness
308.2		Acute reaction to stress, predominant psychomotor disturbance
308.3		Other acute reactions to stress
308.4		Mixed disorders as reaction to stress
308.9		Unspecified acute reaction to stress
309.0		Adjustment disorder with depressed mood
309.1		Adjustment reaction, prolonged depressive reaction
309.21		Adjustment reaction, separation anxiety disorder
309.24		Adjustment disorder with anxiety
309.28		Adjustment disorder with mixed anxiety and depressed mood
309.29		Adjustment reaction, with predominant disturbance of other emotions, other
309.3		Adjustment disorder with disturbance of conduct
309.4		Adjustment disorder with mixed disturbance of emotions and conduct
309.81		Posttraumatic stress disorder
309.82		Adjustment reaction with physical symptoms
309.83		Adjustment reaction with withdrawal
309.89		Adjustment reaction, other
309.9		Unspecified adjustment reaction
310.0		Frontal lobe syndrome
310.1		Personality change due to conditions classified elsewhere
310.2		Post concussion syndrome
310.8		Other specified nonpsychotic mental disorders following organic brain damage
310.9		Unspecified nonpsychotic mental disorder following organic brain damage
311		Depressive disorder, not elsewhere classified
312.00		Undersocialized conduct disorder, aggressive type, unspecified
312.01		Undersocialized conduct disorder, aggressive type, mild
312.02		Undersocialized conduct disorder, aggressive type, moderate
312.03		Undersocialized conduct disorder, aggressive type, severe
312.10		Undersocialized conduct disorder, unaggressive type, unspecified
312.11		Undersocialized conduct disorder, unaggressive type, mild
312.12		Undersocialized conduct disorder, unaggressive type, moderate
312.13		Undersocialized conduct disorder, unaggressive type, severe
312.20		Socialized conduct disorder, unspecified
312.21		Socialized conduct disorder, mild
312.22		Socialized conduct disorder, moderate
312.23		Socialized conduct disorder, severe
312.30		Impulse control disorder, unspecified
312.31		Pathological gambling
312.32		Kleptomania
312.33		Pyromania
312.34		Intermittent explosive disorder
312.35		Isolated explosive disorder
312.39		Disorders of impulse control, not elsewhere classified, other
312.4		Mixed disturbance of conduct and emotions
312.81		Conduct disorder, childhood onset type
312.82		Conduct disorder, adolescent onset type
312.89		Other conduct disorder
312.9		Unspecified disturbance of conduct
313.0		Overanxious disorder
313.1		Misery and unhappiness disorder
313.21		Shyness disorder of childhood
313.22		Introverted disorder of childhood
313.23		Selective mutism
313.3		Relationship problems
313.81		Oppositional defiant disorder
313.82		Disturbance of emotions, childhood and adolescence, identity disorder
313.83		Academic underachievement disorder
313.89		Disturbance of emotions, childhood and adolescence, other
313.9		Unspecified emotional disturbance of childhood or adolescence
314.00		Attention deficit disorder, without mention of hyperactivity
314.01		Attention deficit disorder with hyperactivity
314.1		Hyperkinesis with developmental delay
314.2		Hyperkinetic conduct disorder
314.8		Other specified manifestations of hyperkinetic syndrome
314.9		Unspecified hyperkinetic syndrome
315.00		Reading disorder, unspecified
315.1		Mathematic disorders
315.2		Other specific learning difficulties
315.31		Expressive language disorder
315.32		Mixed receptive-expressive language disorder
315.39		Developmental speech or language disorder, other
315.4		Developmental coordination disorder
315.5		Mixed development disorder
315.8		Other specified delays in development
315.9		Unspecified delay in development
316		Psychic factors associated with diseases classified elsewhere
332.1		Secondary Parkinsonism
333.1		Essential and other specified forms of tremor
333.7		Symptomatic torsion dystonia
333.82		Orofacial dyskinesia
333.90		Unspecified extrapyramidal disease and abnormal movement disorder
333.92		Neuroleptic malignant syndrome
333.99		Other and unspecified extrapyramidal diseases and abnormal movement
		disorders, other
347.00		Narcolepsy without cataplexy
347.01		Narcolepsy with cataplexy
347.10		Narcolepsy in conditions classified elsewhere without cataplexy
347.11		Narcolepsy in conditions classified elsewhere with cataplexy
780.09		Alteration of consciousness, other
780.52		Sleep disturbances, other insomnia
780.54		Sleep disturbances, other hypersomnia
780.58		Sleep related movement disorder
780.59		Sleep disturbances, other
995.2		Unspecified adverse effect of drug, medicinal and biological substance
V61.10		Counseling for marital and partner problems, unspecified
V61.11		Counseling for victim of spousal and partner abuse
V61.12		Counseling for perpetrator of spousal and partner abuse
V61.20		Counseling for parent-child problem, unspecified
V61.21		Counseling for victim of child abuse
V62.82		Counseling for perpetrator of parental child abuse
V71.02		Observation for suspected childhood or adolescent antisocial behavior

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

Services are provided for an indication not listed in the "Indications and Limitations of Coverage" section of this policy.
The service is for screening purposes.
The services are duplicative (two providers providing the same service). This does not refer to two separate therapies provided on the same day.
The service is not considered medically reasonable and necessary, such as:

day care programs, which provide primarily social, recreational, or diversional activities, custodial or respite care
programs attempting to enhance emotional wellness, e.g., day care programs
services to a skilled nursing facility resident that should be expected to be provided by the nursing facility staff
vocational training when services are related to specific employment opportunities, work skills, or work settings
biofeedback training for psychosomatic conditions
recovery meetings such as Alcoholics Anonymous, 12 Step, Al Anon, Narcotics Anonymous, etc.
telephone calls to collateral resources and agencies
evaluation of records, reports, tests, and other data
explanation of results to family, or others
preparation of reports for agencies, courts, schools, or insurance companies, etc. for medicolegal or informational purposes
services for patients who cannot or refuse to participate (due to their behavioral, cognitive, or emotional status) with active treatment of their mental disorder
services for patients who require 24 hour supervision (inpatient care) because of the severity of their mental disorder, or for their safety or the safety of others
services for patients who have met the criteria for discharge from outpatient hospital psychiatric services, or who require a higher level of care, including inpatient hospitalization

The service is investigational.
The service is cosmetic.
The service is a program exclusion.
The medical record does not verify that the service described by the HCPCS code was provided.
A physician-approved treatment plan has not been documented.
"Incident to" provisions have not been followed, including ongoing active involvement of the physician in the patient's care.
The service does not follow the guidelines of this policy.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

To report this service, use the appropriate CPT/HCPCS code

Revenue	Description	CPT/HCPCS Codes
250	Pharmacy	Not Applicable
43X	Occupational Therapy	97003, 97004, 97530, 97532, 97533, 97535, 97537
901	Electroshock	90870
914	Individual Therapy	90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90812, 90814, 90862
915	Group Therapy	90853, 90857
916	Family Therapy	90846, 90847
918	Psychiatric Testing	96100, 96110, 96111, 96115, 96117
944	Drug Rehabilitation	90804, 90806, 90808, 90810, 90812, 90814, 90853, 90857
945	Alcohol Rehabilitation	90804, 90806, 90808, 90810, 90812, 90814, 90853, 90857

This policy does not address physician Evaluation and Management services. E&M codes may be used by physicians when these codes represent the services provided more accurately than the Psychiatric codes. Procedure code 99211 may be used by non-physicians for E&M services that may not require the presence of a physician.
All of the coverage criteria must be met before this service can be reimbursed by Medicare
Diagnosis (es) must be present on any claim submitted, and be coded to the highest level of specificity
The diagnosis codes(s) must be representative of the patient's condition
Procedure code 90801 should be used once at the onset of an illness or suspected illness. It may be utilized again for the same patient if a new episode of illness occurs after a hiatus, or on admission or re-admission to inpatient status due to complications of the underlying condition.
Psychiatric therapy procedure codes 90804-90829 should not be billed on the same date of service as an E&M service for the same patient by the same mental health professional group.
Procedure code 90849, multiple-family group therapy, is a non-covered service, as it is not directly beneficial to the patient.
Procedure codes 90853 and 90857, group therapy, should be restricted to groups of ten or less participants.
Procedure code 90862, pharmacologic management, should not be billed separately on the same date of service as a psychotherapy service by the same physician. Procedure code 90862 should not be billed with E&M codes on the same date of service by the same physician. This code is a physician service, and is not intended to be used for the 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.
Procedure code 90885, evaluation of records, is considered a bundled service and is not separately payable.

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.
Upon initiation of outpatient psychiatric services, an initial psychiatric evaluation needs to be performed and placed on the chart in order to establish the medical necessity for these services. An appropriate update to an inpatient or partial hospitalization admission note is acceptable documentation. This evaluation should include the following:

Patient's chief complaint
Description of the acute illness or the exacerbation of the chronic illness requiring treatment
Current medical history, including medications and supporting evidence for the hospital outpatient level of service
Past psychiatric and medical history
History of substance abuse
Family, vocational and social history
Mental status exam
Physical exam if needed
ICD-9-CM/DSM-IV diagnoses

An individualized treatment plan that has been approved by the treating physician must be included in the documentation. The treatment plan should include long and short-term goals related to the active treatment of the patient's diagnosis, and the therapies to be used to achieve those goals, including type, amount, duration and frequency of these interventions.
The initial evaluation and treatment plan may be the result of a team effort, but the physician needs to document the mental status examination, physical examination (when appropriate), assessment, diagnoses, and prescription of services. The need for all services provided in the treatment plan should be documented by the physician.
The individual treatment plan should be reviewed by the physician, at a minimum, every 31 days. The treatment plan should be reviewed and updated more often as clinically appropriate. All changes in therapy should be reflected in the updated treatment plan. (In those instances when a patient is being seen less frequently than once every 31 days, documentation of the patient's visit, including goals and proposed interventions, should be forwarded to the treating physician for a co-signature, which should then be included in the patient's record.)
The short and long-term treatment goals should be used to evaluate the patient's response to therapy. Progress towards these goals must be documented to support the medical necessity of continuing hospital outpatient psychiatric services.

Training and educational services should be clearly related to the care and treatment of the patient's mental health problems, and the goals for these services should be outlined in the treatment plan.
A separate progress note is required for each service rendered, either by the physician or non-physician practitioner rendering the service. Each progress note should be dated and signed by the rendering practitioner, and include that practitioner's credentials. The note should include the patient's status, the service rendered, and the patient's response to the intervention in terms of the patient's treatment goals.

Utilization Guidelines

Medicare will monitor the utilization of these outpatient services through the Medical Review process.

Other Comments

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient or their authorized representative in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary or their authorized representative was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary or their authorized beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary or their authorized representative. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

Medicare Part A Template Local Medical Review Policy for Outpatient Hospital Psychiatric Services

Advisory Committee 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 the appropriate specialty(ies).

Start Date of Comment Period

06/17/2003

End Date of Comment Period

08/01/2003

Start Date of Notice Period

11/14/2003

Revision History

Number	Date	Change
R1	10/01/2004	Per CRs 3194 & 3343-discontinued use of revenue
		code 910 and added 900. Effective 10/16/2003,
		implemented 10/04/2004. Annual ICD-9 update per
		Transmittal 210, CR 3303. See article on website
		for specific ICD-9 changes.
03-06	2/01/2004	Policy number changed to 04-01 as it became effective in
		FY 2004.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.