Approved providers of mental health services:
1. Psychiatrists are physicians (MDs and DOs) trained in mental health disorders and may provide all services described in this policy.
2. For a Clinical Psychologist (CP) to qualify as a provider, the practitioner must meet the following requirements:
- Hold a doctoral degree in psychology.
- Be licensed or certified on the basis of the doctoral degree in psychology by the state in which he practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive and therapeutic services directly to individuals.
- For a Clinical Social Worker (CSW) to qualify as a provider, the candidate must meet the following requirements:
- Possess a master’s or doctoral degree in social work.
- Performed at least two years of supervised clinical social work.
Either:
- Is licensed or certified as a clinical social worker by the state in which the services are performed.
Or:
- In the case of an individual in a state that does not provide for licensure or certification, has completed at least two years or 3,000 hours of post-master’s degree supervised clinical social work practice under the supervision of a master’s-level social worker in an appropriate setting such as a hospital, SNF or clinic.
Note: CSWs are reimbursed for psychological/psychiatric services at 75 percent of the Medicare physician’s fee schedule allowance for services rendered.
4. Psychiatric Nurse Practitioners (PNPs) must meet the following requirements:
Either:
- Be a registered professional nurse who is authorized by the state in which the services are furnished to practice as a nurse practitioner in accordance with state law.
- Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners (see additional detail in “Other Comments” section of the attached article).
- Possess a master’s degree or higher in nursing.
Or:
- Be a registered professional nurse who is authorized by the state in which the services are furnished to practice as a nurse practitioner by December 31, 2000.
Note: Nurse Practitioners/Advanced Practice Nurses (NPs) may perform services within their scope of practice, as determined by the relevant State Board of Nursing. (To perform psychotherapy and other psychiatric services, they must be licensed as a nurse practitioner certified in psychiatric nursing by the state or jurisdiction.)
5. Clinical Nurse Specialists (CNSs) must meet the following requirements:
- Be a registered nurse who is currently licensed to practice in the state where he practices and be authorized to furnish the services of a CNS in accordance with state law.
- Currently possess a master’s degree or higher in a defined clinical area (psychiatric services) of nursing from an accredited educational institution.
- Be certified as a CNS by a recognized national certifying body that has established standards for CNSs (see additional detail in “Other Comments” section of the attached article).
6. Physician Assistant (PA) services are covered by Medicare when they meet the following criteria:
- The PA has graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission of Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA)).
Or:
- The PA has passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA).
- The PA is licensed by the state or jurisdiction to practice as a physician assistant.
- The PA is required to bill Medicare for approved services through the provider, physician or physician group by which he is employed.
Coverage for all non-physician practitioners is limited to services that they are authorized to perform by the states in which the services are furnished. The coverage sections within this policy will provide this information for each section of listed CPT codes.
For Mental Health Services Under the “Incident to” Provision, refer to the Benefit Policy Manual, Pub. 100-02, Chapter 15, Sections 60 and 80.2.
Outpatient Mental Health Treatment Limitation:
Section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 amends Section 1833 of the Social Security Act to phase out the outpatient mental health treatment limitation over a five-year period from 2010–2014. The limitation will change as follows: 2009 and prior years = 62.5 percent; 2010–2011 = 68.75 percent; 2012 = 75 percent; 2013 = 81.25 percent; and 2014 onward = 100 percent. When the MIPPA provision is fully implemented (January 1, 2014), the outpatient mental health services will be paid at the same rate as other Part B services, and Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be paid at 80 percent of their encounter rate, subject to the applicable upper payment limit.
For phase–out details, see:
- Medicare General Information, Eligibility and Entitlement – Pub. 100-01:
- Chapter 3, Section 30.
For application details, see:
- Medicare Benefit Policy Manual – Pub. 100-02:
- Chapter 13, Sections 100.6 and 110.5.
- Medicare Claims Processing Manual – Pub. 100-04:
- Chapter 5, Section 100.4.
- Chapter 9, Section 60.
- Chapter 12, Section 110.2, 120, 170.1, 210 and 210.1.
Section I: Psychiatric Diagnostic Interview Examinations (90801, 90802)
1. The diagnostic interview is indicated for initial or periodic diagnostic evaluation of a patient for suspected or diagnosed psychiatric illness. A second provider seeing the patient for the first time may also use this code.
2. It may be utilized again for the same patient if a new episode of illness occurs, an admission or a readmission to inpatient status due to complications of the underlying condition occurs, or when re-evaluation is required to address a new referral question. Certain patients, especially children and geriatric patients may require more than one visit for the completion of the initial diagnostic evaluation. The indication for the assessment should be based on medical necessity.
3. Interactive procedures are covered for patients whose ability to communicate is impaired by expressive or receptive language impairment from various causes. These may include conductive or sensorineural hearing loss, deaf mutism, aphasia, language barrier, or lack of mental development (childhood).
Coverage for the diagnostic interview is limited to MDs, DOs, CSWs, CPs, CNSs, PAs and NPs certified in the state or jurisdiction for psychiatric services.
Section II: Psychological and Neuropsychological Testing
1. These diagnostic tests are used when mental illness is suspected, and clarification is essential for the diagnosis and the treatment plan.
2. Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.
3. Examples of problems that might require psychological and/or neuropsychological testing include:
- Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis and/or treatment planning.
- Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present.
- Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management.
- Differential diagnosis between psychogenic and neurogenic syndromes (e.g., depression versus dementia).
- Detection of neurologic disease based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, Acquired Immune Deficiency Syndrome (AIDS) dementia).
- Delineation of the neurocognitive effects of central nervous system disorders.
- Neurocognitive monitoring of recovery or progression of central nervous system disorders.
4. Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically necessary.
5. When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include:
- A significant change in the patient’s condition.
- The need to evaluate a patient’s capacity to function in a given situation or environment.
- The need to specifically tailor therapeutic and or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities.
6. Adjustment reactions or dysphoria associated with moving to a nursing home do not automatically constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline, and may require psychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Medical necessity of such evaluations should be documented and maintained in the medical record.
7. Each test administered must be medically necessary. Standardized batteries of tests are only acceptable if each component test is medically necessary.
8. Depending on the issues to be assessed, a typical test battery may require seven to 10 hours to perform, including administration, scoring and interpretation.
9. Code 96105 represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented. If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.
10. 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 psychological or neuropsychological testing, since they are typically part of a more general clinical exam or interview.
11. Psychological/neuropsychological testing codes should not be reported by the treating physician for only readingthe results of the testing. The reading of the report is included in the office or floor time in the hospital and would be included in the evaluation and management service for that day.
12. Medicare does not authorize payment for psychological and neuropsychological testing when performed on an “incident to” basis (Pub. 100-02, Chapter 15, Section 80.2).
13. PTs, Occupational Therapists (OTs), and SLPs are authorized to bill three test codes as “sometimes therapy” codes. These therapists may perform CPT codes 96105, 96110 and 96111; however, they must be performed under the general supervision of a physician or a CP.
14. Non-physician practitioners (NPPs), such as NPs, CNSs and PAs who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP (Pub. 100-02, Chapter 15, Section 80.2).
15. Independently Practicing Psychologists (IPPs) may bill for psychological and neuropsychological tests when the tests are ordered by a physician (Pub. 100-02, Chapter 15, Section 80.2).
Section III: Psychotherapy Services
1. Psychotherapy services must be comprised of clinically recognized therapies that are pertinent to the patient’s illness or condition. The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted practice standards.
2. There must be a reasonable expectation of improvement in the patient’s disorder or condition, demonstrated by an improved level of functioning, or maintenance of level of functioning where decline would otherwise be expected in the case of a disabling mental illness or condition, or chronic mental disorders.
3. The patient must have the capacity to actively participate in all therapies prescribed.
4. To benefit from psychotherapy, an individual must be cognitively intact to the degree that he can engage in a meaningful verbal interaction with the therapist. Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent establishment of a relationship with the therapist, which allows insight-oriented, behavior-modifying or supportive therapy to be effective. The type and degree of dementia must be taken into account in planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a patient with dementia, the patient’s record should document that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.
5. Psychotherapy services are never covered for severe and profound mental retardation (ICD-9-CM codes 318.1 and 318.2).
6. Psychotherapy codes should not be used when an E/M code would be more appropriate.
7. The duration of psychotherapy must be individualized for every patient. Prolonged treatment may warrant medical necessity review. The provider of service must document in the patient’s record the medical necessity for continued (prolonged) treatments.
8. Procedure codes 90808, 90809, 90814, 90815, 90821, 90822, 90828 and 90829 represent services lasting approximately 75 to 80 minutes. The provider must document in the patient’s medical record the medical necessity of these services and define the extended services. Medicare anticipates that these extended services will be utilized in times of exceptional need.
9. Medicare coverage of psychotherapy procedures does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction. Therefore, these procedure codes should not be used to bill for Activities of Daily Living (ADL) training and/or socialization activities.
10. Interactive procedures are covered for patients whose ability to communicate is impaired by an expressive or receptive language impairment from various causes. These may include conductive or sensorineural hearing loss, deaf mutism, aphasia, language barrier, or lack of mental development (childhood).
11. Group therapy (90853 and 90857) sessions should not exceed 10 participants and should be at least 45 to 60 minutes in duration. While a video or movie may be used as an adjunct to the sessions, this modality should not be used as a replacement for the therapist’s active participation and the majority of the session should involve the interaction between the participants and the therapist leading the session. If group psychotherapy is provided to a patient with dementia, the patient’s record should document that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.
12. Medicare coverage of family therapy codes 90846, 90847 and 90849 is extended whenever medically necessary.
13. Codes 90846 and 90847 will be considered for payment under Medicare only for treatment of the Medicare beneficiary’s mental illness. Family therapy is appropriate when intervention in the family interactions would be expected to improve or stabilize the patient’s emotional/behavioral disturbance. Family therapy sessions with a patient whose emotional disturbance would be unaffected by changes in the patterns of family interaction (i.e., a comatose patient) would not be covered by Medicare. Similarly, an emotional disturbance in a family member, which does not impact on the Medicare patient’s status, would not be covered by that patient’s Medicare benefits. Family therapy is commonly the major treatment, especially for children and also for the elderly. Where both husband and wife are covered by Medicare, such therapy may be the most parsimonious treatment for both.
- Code 90846 (family psychotherapy without the patient present) does not represent routine consultation with staff about the patient’s progress and treatment. Facility staff members are not considered caregivers for purposes of this policy; however, caretakers in group-living facilities may be considered caregivers for the purpose of these policies.
- Code 90849 (multiple family psychotherapy) is generally non-covered. Such group therapy is directed to the effect of the patient’s condition on the family and does not meet Medicare’s standards of being part of the personal service to the patient. If such is not the case, individual consideration may be given if documentation is submitted.
14. All psychotherapy services described in this section are payable to psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse practitioners, CNSs and PAs with these exceptions:
- CSWs are not eligible for payment for inpatient services (defined as inpatient hospital settings, partial hospitalization settings or skilled nursing homes for beneficiaries who are at that time receiving benefits under Medicare Part A payment for skilled services) represented by these codes: 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828 and 90829.
- Psychoanalysis (90845) is not covered for CNSs.
- Psychotherapy codes that include an E/M component (90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827 and 90829) are payable only to MDs, DOs, qualified CNSs, nurse practitioners and PAs. Each element of these services (therapy and E/M) must be reasonable and necessary and should be documented in the patient’s records.
Section IV: Pharmacologic Management of Psychiatric Illness (90862, M0064)
Pharmacologic management (90862) is intended for use for patients who are being managed primarily by psychotropics, antidepressants, Electroconvulsive Therapy (ECT) and/or other types of psychopharmacologic medications. It refers to the in-depth management of psychopharmacologic agents that are potent medications with frequent serious side effects and represents a very skilled aspect of patient care.
Codes 90862 and M0064 describe a physician service and cannot be billed by a non-physician or “incident to” a physician’s service, with the exception of nurse practitioners, CNSs and PAs whose scope of license in their states permits them to prescribe.
Section V: Other Psychiatric and Psychological Services (90865, 90870)
- Narcosynthesis is indicated for patients who have difficulty verbalizing psychiatric problems without the aid of the drug.
- ECT is used in the treatment of depression and related disorders and other severe psychiatric conditions.
- When a psychiatrist administers the anesthesia for the ECT procedure, no separate payment is made for the anesthesia service.
Allowed unit limitations (once per provider, per discipline, per date of service, per patient) by discipline for CPT codes 96110 and 96111 are described in the “Utilization Guidelines” section below.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
N/A
Revenue Codes
N/A
CPT/HCPCS Codes
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Note:
|
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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90801©
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Psy dx interview
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|
90802©
|
Intac psy dx interview
|
|
90804©
|
Psytx, office, 20–30 min
|
|
90805©
|
Psytx, off, 20–30 min w/e&m
|
|
90806©
|
Psytx, office, 45–50 min
|
|
90807©
|
Psytx, office, 45–50 min w/e&m
|
|
90808©
|
Psytx, office, 75–80 min
|
|
90809©
|
Psytx, office, 75–80 min w/e&m
|
|
90810©
|
Intac psytx, off, 20–30 min
|
|
90811©
|
Intac psytx, off, 20–30 min w/e&m
|
|
90812©
|
Intac psytx, off, 45–50 min
|
|
90813©
|
Intac psytx, off, 45–50 min w/e&m
|
|
90814©
|
Intac psytx, off, 75–80 min
|
|
90815©
|
Intac psytx, off, 75–80 min w/e&m
|
|
90816©
|
Psytx, hosp, 20–30 min
|
|
90817©
|
Psytx, hosp, 20–30 min w/e&m
|
|
90818©
|
Psytx, hosp, 45–50 min
|
|
90819©
|
Psytx, hosp, 45–50 min w/e&m
|
|
90821©
|
Psytx, hosp, 75–80 min
|
|
90822©
|
Psytx, hosp, 75–80 min w/e&m
|
|
90823©
|
Intac psytx, hosp, 20–30 min
|
|
90824©
|
Intac psytx, hosp, 20–30 min w/e&m
|
|
90826©
|
Intac psytx, hosp, 45–50 min
|
|
90827©
|
Intac psytx, hosp, 45–50 min w/e&m
|
|
90828©
|
Intac psytx, hosp, 75–80 min
|
|
90829©
|
Intac psytx, hosp, 75–80 min w/e&m
|
|
90845©
|
Psychoanalysis
|
|
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©
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Narcosynthesis
|
|
90870©
|
Electroconvulsive therapy
|
|
90880©
|
Hypnotherapy
|
|
90889©
|
Preparation of report
|
|
90899©
|
Psychiatric service/therapy
|
|
96101©
|
Psycho testing by psych/phys
|
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96102©
|
Psycho testing by technician
|
|
96103©
|
Psycho testing admin by comp
|
|
96105©
|
Assessment of aphasia
|
|
96110©
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Developmental test, lim
|
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96111©
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Developmental test, extend
|
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96116©
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Neurobehavioral status exam
|
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Note: Must be accomplished by psychologist or physician (see CPT code long description).
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|
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96118©
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Neuropsych tst by psych/phys
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96119©
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Neuropsych testing by tech
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96120©
|
Neuropsych tst admin w/comp
|
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96125©
|
Cognitive test by hc pro
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M0064
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Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders
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ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to procedure to diagnosis editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Sections I and II: Diagnostic/Assessment Services
Medicare is establishing the following limited coverage for CPT/HCPCS codes 90801, 90802, 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120 and 96125:
Covered for:
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290.0
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Senile dementia, uncomplicated
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290.10-290.13
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Presenile dementia
|
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290.20–290.21
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Senile dementia with delusional or depressive features
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290.3
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Senile dementia with delirium
|
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290.40–290.43
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Atherosclerotic dementia
|
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290.8–290.9
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Senile and presenile organic psychotic conditions
|
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291.0–291.5
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Alcoholic psychosis
|
|
291.81–291.82
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Other specified alcohol-induced mental disorders
|
|
291.89
|
Other specified alcohol-induced mental disorders
|
|
291.9
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Unspecified alcohol-induced mental disorders
|
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292.0
|
Drug withdrawal
|
|
292.11–292.12
|
Paranoid and/or hallucinatory states induced by drugs
|
|
292.2
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Pathological drug intoxication
|
|
292.81–292.85
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Other specified drug-induced mental disorders
|
|
292.89
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Other specified drug-induced mental disorders
|
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292.9
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Unspecified drug-induced mental disorder
|
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293.0–293.1
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Transient organic psychotic conditions
|
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293.81–293.84
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Other specified transient organic mental disorders
|
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293.89
|
Other specified transient mental disorders due to conditions classified elsewhere, other
|
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293.9
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Unspecified transient mental disorder in conditions classified elsewhere
|
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294.0
|
Amnestic disorder in conditions classified elsewhere
|
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294.10–294.11
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Dementia in conditions classified elsewhere
|
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294.8–294.9
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Other specified/unspecified organic brain syndromes
|
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295.00–295.05
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Schizophrenic disorders (simple)
|
|
295.10–295.15
|
Schizophrenic disorders (disorganized)
|
|
295.20–295.25
|
Schizophrenic disorders (catatonic)
|
|
295.30–295.35
|
Schizophrenic disorders (paranoid)
|
|
295.40–295.45
|
Schizophrenic disorders (acute schizophrenic episode)
|
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295.50–295.55
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Schizophrenic disorders (latent schizophrenia)
|
|
295.60–295.65
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Schizophrenic disorders (residual schizophrenia)
|
|
295.70–295.75
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Schizophrenic disorders (schizo-affective)
|
|
295.80–295.85
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Schizophrenic disorders (other specified types)
|
|
295.90–295.95
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Schizophrenic disorders (unspecified schizophrenia)
|
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296.00–296.06
|
Affective disorders (manic -single episode)
|
|
296.10–296.16
|
Affective disorders (manic – recurrent episode)
|
|
296.20–296.26
|
Affective disorders (major depressive – single episode)
|
|
296.30–296.36
|
Affective disorders (major depressive – recurrent episode)
|
|
296.40–296.46
|
Affective disorders (bipolar affective – manic)
|
|
296.50–296.56
|
Affective disorders (bipolar affective – depressed)
|
|
296.60–296.66
|
Affective disorders (bipolar affective – mixed)
|
|
296.7
|
Bipolar I disorder, most recent episode (or current) unspecified
|
|
296.80–296.82
|
Affective disorders (manic-depressive psychosis)
|
|
296.89
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Other and unspecified bipolar disorders, other
|
|
296.90
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Unspecified episodic mood disorder
|
|
296.99
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Other specified episodic mood disorder
|
|
297.0–297.3
|
Paranoid states (delusional disorders)
|
|
297.8–297.9
|
Paranoid states (delusional disorders)
|
|
298.0–298.4
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Other non-organic psychoses
|
|
298.8–298.9
|
Other non-organic psychoses
|
|
299.00–299.01
|
Psychoses with origin specific to childhood (infantile autism)
|
|
299.10–299.11
|
Psychoses with origin specific to childhood (disintegrative psychosis)
|
|
299.80–299.81
|
Psychoses with origin specific to childhood (other specified)
|
|
299.90–299.91
|
Psychoses with origin specific to childhood (unspecified)
|
|
300.00–300.02
|
Anxiety states
|
|
300.09
|
Anxiety states
|
|
300.10–300.16
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Hysteria
|
|
300.19
|
Hysteria
|
|
300.20–300.23
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Phobic disorders
|
|
300.29
|
Other isolated or specific phobias
|
|
300.3–300.7
|
Neurotic disorders
|
|
300.81–300.82
|
Other neurotic disorders
|
|
300.89
|
Other somatoform disorders
|
|
300.9
|
Unspecified non-psychotic mental disorder
|
|
301.0
|
(Paranoid) personality disorder
|
|
301.10–301.13
|
(Affective) personality disorder
|
|
301.20–301.22
|
(Schizoid) personality disorder
|
|
301.3–301.4
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Personality disorder
|
|
301.50–301.51
|
(Histrionic) personality disorder
|
|
301.59
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(Histrionic) personality disorder
|
|
301.6–301.7
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Personality disorder
|
|
301.81–301.84
|
Personality disorder (other)
|
|
301.89
|
Personality disorder (other)
|
|
301.9
|
Personality disorder (unspecified)
|
|
302.1–302.4
|
Sexual deviations and disorders
|
|
302.50–302.53
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Sexual deviations and disorders (trans-sexualism)
|
|
302.6
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Gender identity disorder in children
|
|
302.70–302.76
|
Sexual deviations and disorders (psychosexual dysfunction)
|
|
302.79
|
Sexual deviations and disorders (psychosexual dysfunction)
|
|
302.81–302.85
|
Sexual deviations and disorders (other specified disorders)
|
|
302.89
|
Sexual deviations and disorders (other specified disorders)
|
|
302.9
|
Sexual deviations and disorders (unspecified)
|
|
303.00–303.03
|
Alcohol dependence syndrome (acute alcoholic intoxication)
|
|
303.90–303.93
|
Alcohol dependence syndrome (other and unspecified)
|
|
304.00–304.03
|
Drug dependence (opioid type)
|
|
304.10–304.13
|
Drug dependence (barbiturate & similarly acting sedative or hypnotic)
|
|
304.20–304.23
|
Drug dependence (cocaine)
|
|
304.30–304.33
|
Drug dependence (cannabis)
|
|
304.40–304.43
|
Drug dependence (amphetamine & other psychostimulant)
|
|
304.50–304.53
|
Drug dependence (hallucinogen)
|
|
304.60–304.63
|
Drug dependence (other specified)
|
|
304.70–304.73
|
Drug dependence (combination opioid + any other)
|
|
304.80–304.83
|
Drug dependence (combination excluding opioid)
|
|
304.90–304.93
|
Drug dependence (unspecified)
|
|
305.00–305.03
|
Non-dependent abuse of drugs (alcohol)
|
|
305.1
|
Tobacco use disorder
|
|
305.20–305.23
|
Non-dependent abuse of drugs (cannabis)
|
|
305.30–305.33
|
Non-dependent abuse of drugs (hallucinogen)
|
|
305.40–305.43
|
Non-dependent abuse of drugs (barbiturate & similarly acting sedative or hypnotic)
|
|
305.50–305.53
|
Non-dependent abuse of drugs (opioid)
|
|
305.60–305.63
|
Non-dependent abuse of drugs (cocaine)
|
|
305.70–305.73
|
Non-dependent abuse of drugs (amphetamine & other psychostimulant)
|
|
305.80–305.83
|
Non-dependent abuse of drugs (antidepressant)
|
|
305.90–305.93
|
Non-dependent abuse of drugs (other mixed or unspecified)
|
|
306.0–306.4
|
Physiological malfunction arising from mental factors
|
|
306.50–306.53
|
Physiological malfunction arising from mental factors (genitourinary)
|
|
306.59
|
Physiological malfunction arising from mental factors (genitourinary)
|
|
306.6–306.9
|
Physiological malfunction arising from mental factors
|
|
307.0–307.1
|
Special symptoms or syndromes, not elsewhere classified
|
|
307.20–307.23
|
Special symptoms or syndromes, not elsewhere classified (tics)
|
|
307.3
|
Stereotypic movement disorder
|
|
307.40–307.49
|
Special symptoms or syndromes, not elsewhere classified (sleep disorders, nonorganic)
|
|
307.50–307.54
|
Special symptoms or syndromes, not elsewhere classified (eating disorders)
|
|
307.59
|
Special symptoms or syndromes, not elsewhere classified (eating disorders)
|
|
307.6–307.7
|
Special symptoms or syndromes, not elsewhere classified
|
|
307.80–307.81
|
Special symptoms or syndromes, not elsewhere classified (psychalgia)
|
|
307.89
|
Other, pain disorder related to psychological factors
|
|
307.9
|
Other and unspecified symptoms or syndromes, NEC
|
|
308.0–308.4
|
Acute reaction to stress
|
|
308.9
|
Acute reaction to stress
|
|
309.0–309.1
|
Adjustment reaction
|
|
309.21–309.24
|
Adjustment reaction with predominant disturbance of other emotions
|
|
309.28–309.29
|
Adjustment reaction with predominant disturbance of other emotions
|
|
309.3–309.4
|
Adjustment reaction
|
|
309.81–309.83
|
Adjustment reaction (other specified)
|
|
309.89
|
Adjustment reaction (other specified)
|
|
309.9
|
Adjustment reaction (unspecified)
|
|
310.0–310.2
|
Specific non-psychotic mental disorders due to organic brain damage
|
|
310.8–310.9
|
Specific non-psychotic mental disorders due to organic brain damage
|
|
311
|
Depressive disorder, not elsewhere classified
|
|
312.00–312.03
|
Undersocialized conduct disorder, aggressive type
|
|
312.10–312.13
|
Undersocialized conduct disorder, unaggressive type
|
|
312.20–312.23
|
Socialized conduct disorder
|
|
312.30–312.35
|
Disorders of impulse control, not elsewhere classified
|
|
312.39
|
Disorders of impulse control, not elsewhere classified
|
|
312.4
|
Mixed disturbance of conduct and emotions
|
|
312.81–312.82
|
Other specified disturbances of conduct, not elsewhere classified
|
|
312.89
|
Other specified disturbances of conduct, not elsewhere classified
|
|
312.9
|
Unspecified disturbance of conduct
|
|
313.0–313.1
|
Disturbance of emotions specific to childhood and adolescence
|
|
313.21–313.23
|
Sensitivity, shyness, and social withdrawal disorder
|
|
313.3
|
Relationship problems
|
|
313.81–313.83
|
Other or mixed emotional disturbances of childhood or adolescence
|
|
313.89
|
Other or mixed emotional disturbances of childhood or adolescence
|
|
313.9
|
Unspecified emotional disturbance of childhood or adolescence
|
|
314.00–314.01
|
Attention deficit disorder
|
|
314.1–314.2
|
Hyperkinetic syndrome of childhood
|
|
314.8–314.9
|
Hyperkinetic syndrome of childhood
|
|
315.00–315.02
|
Specific reading disorder
|
|
315.09
|
Specific reading disorder
|
|
315.1–315.2
|
Specific delays in development
|
|
315.31–315.32
|
Developmental speech or language disorder
|
|
315.39
|
Developmental speech or language disorder
|
|
315.4–315.5
|
Specific delays in development
|
|
315.8–315.9
|
Unspecified and other specified delays in development
|
|
316
|
Psychic factors associated with diseases classified elsewhere
|
|
317
|
Mild mental retardation
|
|
318.0–318.2
|
Other specified mental retardation
|
|
319
|
Unspecified mental retardation
|
|
327.02
|
Insomnia due to mental disorder
|
|
327.15
|
Hypersomnia due to mental disorder
|
|
327.42–327.43
|
Organic parasomnia
|
|
331.0
|
Alzheimer’s disease
|
|
331.2
|
Senile degeneration of brain
|
|
332.1
|
Secondary Parkinsonism
|
|
333.1
|
Essential and other specified forms of tremor
|
|
333.71–333.72
|
Acquired torsion dystonia
|
|
333.79
|
Other acquired torsion dystonia
|
|
333.82
|
Orofacial dyskinesia
|
|
333.85
|
Subacute dyskinesia due to drugs
|
|
333.90
|
Unspecified extrapyramidal disease and abnormal movement disorder
|
|
333.92
|
Neuroleptic malignant syndrome
|
|
333.99
|
Other unspecified extrapyramidal disease and abnormal movement disorder (neuroleptic-induced acute akathisia)
|
|
389.7
|
Deaf, nonspeaking, not elsewhere classified
|
|
780.09
|
Alteration of consciousness, other
|
|
780.95
|
Excessive crying of child, adolescent, or adult
|
|
780.97
|
Altered mental status
|
|
784.3
|
Aphasia
|
|
784.51
|
Dysarthria
|
|
784.59
|
Other speech disturbance
|
|
784.60–784.61
|
Other symbolic dysfunction
|
|
784.69
|
Other symbolic dysfunction
|
|
995.20
|
Unspecified adverse effect of unspecified drug, medicinal and biological substance
|
|
995.50–995.55
|
Child maltreatment syndrome
|
|
995.59
|
Child maltreatment syndrome
|
|
995.80–995.85
|
Adult maltreatment
|
Sections III, IV and V: Therapeutic Services
Medicare is establishing the following limited coverage for CPT/HCPCS codes 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90846, 90847, 90849, 90853, 90857, 90862, 90865, 90870, 90880, 90899 and M0064:
Covered for:
|
290.0
|
Senile dementia, uncomplicated
|
|
290.10–290.13
|
Pre Senile dementia
|
|
290.20–290.21
|
Senile dementia with delusional or depressive features
|
|
290.3
|
Senile dementia with delirium
|
|
290.40–290.43
|
Atherosclerotic dementia
|
|
290.8–290.9
|
Senile and presenile organic psychotic conditions
|
|
291.0–291.5
|
Alcoholic psychosis
|
|
291.81–291.82
|
Other specified alcohol-induced mental disorders
|
|
291.89
|
Other specified alcohol-induced mental disorders
|
|
291.9
|
Unspecified alcohol-induced mental disorders
|
|
292.0
|
Drug withdrawal
|
|
292.11–292.12
|
Paranoid and/or hallucinatory states induced by drugs
|
|
292.2
|
Pathological drug intoxication
|
|
292.81–292.85
|
Other specified drug-induced mental disorders
|
|
292.89
|
Other specified drug-induced mental disorders
|
|
292.9
|
Unspecified drug-induced mental disorder
|
|
293.0–293.1
|
Transient organic psychotic conditions
|
|
293.81–293.84
|
Other specified transient organic mental disorders
|
|
293.89
|
Other specified transient mental disorders due to conditions classified elsewhere, other
|
|
293.9
|
Unspecified transient mental disorder in conditions classified elsewhere
|
|
294.0
|
Amnestic disorder in conditions classified elsewhere
|
|
294.10–294.11
|
Other organic psychotic conditions (chronic)
|
|
294.8–294.9
|
Other organic psychotic conditions (chronic)
|
|
295.00–295.05
|
Schizophrenic disorders (simple)
|
|
295.10–295.15
|
Schizophrenic disorders (disorganized)
|
|
295.20–295.25
|
Schizophrenic disorders (catatonic)
|
|
295.30–295.35
|
Schizophrenic disorders (paranoid)
|
|
295.40–295.45
|
Schizophrenic disorders (acute schizophrenic episode)
|
|
295.50–295.55
|
Schizophrenic disorders (latent schizophrenia)
|
|
295.60–295.65
|
Schizophrenic disorders (residual schizophrenia)
|
|
295.70–295.75
|
Schizophrenic disorders (schizo-affective)
|
|
295.80–295.85
|
Schizophrenic disorders (other specified types)
|
|
295.90–295.95
|
Schizophrenic disorders (unspecified schizophrenia)
|
|
296.00–296.06
|
Affective disorders (manic–single episode)
|
|
296.10–296.16
|
Affective disorders (manic – recurrent episode)
|
|
296.20–296.26
|
Affective disorders (major depressive – single episode)
|
|
296.30–296.36
|
Affective disorders (major depressive – recurrent episode)
|
|
296.40–296.46
|
Affective disorders (bipolar affective – manic)
|
|
296.50–296.56
|
Affective disorders (bipolar affective – depressed)
|
|
296.60–296.66
|
Affective disorders (bipolar affective–mixed)
|
|
296.7
|
Bipolar I disorder, most recent episode (or current) unspecified
|
|
296.80–296.82
|
Affective disorders (manic-depressive psychosis)
|
|
296.89
|
Other and unspecified bipolar disorders, other
|
|
296.90
|
Unspecified episodic mood disorder
|
|
296.99
|
Other specified episodic mood disorder
|
|
297.0–297.3
|
Paranoid states (delusional disorders)
|
|
297.8–297.9
|
Paranoid states (delusional disorders)
|
|
298.0–298.4
|
Other non-organic psychoses
|
|
298.8–298.9
|
Other non-organic psychoses
|
|
299.00–299.01
|
Psychoses with origin specific to childhood (infantile autism)
|
|
299.10–299.11
|
Psychoses with origin specific to childhood (disintegrative psychosis)
|
|
299.80–299.81
|
Psychoses with origin specific to childhood (other specified)
|
|
299.90–299.91
|
Psychoses with origin specific to childhood (unspecified)
|
|
300.00–300.02
|
Anxiety states
|
|
300.09
|
Anxiety states
|
|
300.10–300.16
|
Hysteria
|
|
300.19
|
Hysteria
|
|
300.20–300.23
|
Phobic disorders
|
|
300.29
|
Other isolated or specific phobias
|
|
300.3–300.7
|
Neurotic disorders
|
|
300.81–300.82
|
Other neurotic disorders
|
|
300.89
|
Other somatoform disorders
|
|
300.9
|
Unspecified nonpsychotic mental disorder
|
|
301.0
|
(Paranoid) personality disorder
|
|
301.10–301.13
|
(Affective) personality disorder
|
|
301.20–301.22
|
(Schizoid) personality disorder
|
|
301.3–301.4
|
Personality disorders
|
|
301.50–301.51
|
(Histrionic) personality disorder
|
|
301.59
|
(Histrionic) personality disorder
|
|
301.6–301.7
|
Personality disorders
|
|
301.81–301.84
|
Personality disorder (other)
|
|
301.89
|
Personality disorder (other)
|
|
301.9
|
Personality disorder (unspecified)
|
|
302.0–302.4
|
Sexual deviations and disorders
|
|
302.50–302.53
|
Sexual deviations and disorders (trans-sexualism)
|
|
302.6
|
Gender identity disorder in children
|
|
302.70–302.76
|
Sexual deviations and disorders (psychosexual dysfunction)
|
|
302.79
|
Sexual deviations and disorders (psychosexual dysfunction)
|
|
302.81–302.85
|
Sexual deviations and disorders (other specified disorders)
|
|
302.89
|
Sexual deviations and disorders (other specified disorders)
|
|
302.9
|
Sexual deviations and disorders (unspecified)
|
|
303.00–303.03
|
Alcohol dependence syndrome (acute alcoholic intoxication)
|
|
303.90–303.93
|
Alcohol dependence syndrome (other and unspecified)
|
|
304.00–304.03
|
Drug dependence (opioid type)
|
|
304.10–304.13
|
Drug dependence (barbiturate & similarly acting sedative or hypnotic)
|
|
304.20–304.23
|
Drug dependence (cocaine)
|
|
304.30–304.33
|
Drug dependence (cannabis)
|
|
304.40–304.43
|
Drug dependence (amphetamine & other psychostimulant)
|
|
304.50–304.53
|
Drug dependence (hallucinogen)
|
|
304.60–304.63
|
Drug dependence (other specified)
|
|
304.70–304.73
|
Drug dependence (combination opioid + any other)
|
|
304.80–304.83
|
Drug dependence (combination excluding opioid)
|
|
304.90–304.93
|
Drug dependence (unspecified)
|
|
305.00–305.03
|
Non-dependent abuse of drugs (alcohol)
|
|
305.1
|
Tobacco use disorder
|
|
305.20–305.23
|
Non-dependent abuse of drugs (cannabis)
|
|
305.30–305.33
|
Non-dependent abuse of drugs (hallucinogen)
|
|
305.40–305.43
|
Non-dependent abuse of drugs (barbiturate & similarly acting sedative or hypnotic)
|
|
305.50–305.53
|
Non-dependent abuse of drugs (opioid)
|
|
305.60–305.63
|
Non-dependent abuse of drugs (cocaine)
|
|
305.70–305.73
|
Non-dependent abuse of drugs (amphetamine & other psychostimulant)
|
|
305.80–305.83
|
Non-dependent abuse of drugs (antidepressant)
|
|
305.90–305.93
|
Non-dependent abuse of drugs (other mixed or unspecified)
|
|
306.0–306.4
|
Physiological malfunction arising from mental factors
|
|
306.50–306.53
|
Physiological malfunction arising from mental factors (genitourinary)
|
|
306.59
|
Physiological malfunction arising from mental factors (genitourinary)
|
|
306.6–306.9
|
Physiological malfunction arising from mental factors
|
|
307.0–307.1
|
Special symptoms or syndromes, not elsewhere classified
|
|
307.20–307.23
|
Special symptoms or syndromes, not elsewhere classified (tics)
|
|
307.3
|
Stereotypic movement disorder
|
|
307.40–307.49
|
Special symptoms or syndromes, not elsewhere classified (sleep disorders – nonorganic)
|
|
307.50–307.54
|
Special symptoms or syndromes, not elsewhere classified (eating disorders)
|
|
307.59
|
Special symptoms or syndromes, not elsewhere classified (eating disorders)
|
|
307.6–307.7
|
Other and unspecified disorders of eating
|
|
307.80–307.81
|
Special symptoms or syndromes, not elsewhere classified (psychalgia)
|
|
307.89
|
Other, pain disorder related to psychological factors
|
|
307.9
|
Other and unspecified symptoms of syndromes, NEC
|
|
308.0–308.4
|
Acute reaction to stress
|
|
308.9
|
Acute reaction to stress
|
|
309.0–309.1
|
Adjustment reaction
|
|
309.21–309.24
|
Adjustment reaction with predominant disturbance of other emotions
|
|
309.28–309.29
|
Adjustment reaction with predominant disturbance of other emotions
|
|
309.3–309.4
|
Adjustment reaction
|
|
309.81–309.83
|
Adjustment reaction (other specified)
|
|
309.89
|
Adjustment reaction (other specified)
|
|
309.9
|
Adjustment reaction (unspecified)
|
|
310.0–310.2
|
Specific non-psychotic mental disorders due to organic brain damage
|
|
310.8–310.9
|
Specific non-psychotic mental disorders due to organic brain damage
|
|
311
|
Depressive disorder, not elsewhere classified
|
|
312.00–312.03
|
Undersocialized conduct disorder, aggressive type
|
|
312.10–312.13
|
Undersocialized conduct disorder, unaggressive type
|
|
312.20–312.23
|
Socialized conduct disorder
|
|
312.30–312.35
|
Disorders of impulse control, not elsewhere classified
|
|
312.39
|
Disorders of impulse control, not elsewhere classified
|
|
312.4
|
Mixed disturbance of conduct and emotions
|
|
312.81–312.82
|
Other specified disturbances of conduct, not elsewhere classified
|
|
312.89
|
Other specified disturbances of conduct, not elsewhere classified
|
|
312.9
|
Unspecified disturbance of conduct
|
|
313.0–313.1
|
Disturbance of emotions specific to childhood and adolescence
|
|
313.21–313.23
|
Sensitivity, shyness, and social withdrawal disorder
|
|
313.3
|
Relationship problems
|
|
313.81–313.83
|
Other or mixed emotional disturbances of childhood or adolescence
|
|
313.89
|
Other or mixed emotional disturbances of childhood or adolescence
|
|
313.9
|
Unspecified emotional disturbance of childhood or adolescence
|
|
314.00–314.01
|
Attention deficit disorder
|
|
314.1–314.2
|
Hyperkinetic syndrome of childhood
|
|
314.8–314.9
|
Hyperkinetic syndrome of childhood
|
|
315.4
|
Coordination disorder
|
|
315.5
|
Mixed developmental disorder
|
|
315.8
|
Other specified delays in development
|
|
316
|
Psychic factors associated with diseases classified elsewhere
|
|
317
|
Mild mental retardation
|
|
318.0
|
Moderate mental retardation
|
|
318.1–318.2
|
Other specified mental retardation
|
|
327.02
|
Insomnia due to mental disorder
|
|
327.15
|
Hypersomnia due to mental disorder
|
|
327.42–327.43
|
Organic parasomnia
|
|
331.0
|
Alzheimer’s disease
|
|
331.2
|
Senile degeneration of brain
|
|
332.1
|
Secondary Parkinsonism
|
|
333.1
|
Essential and other specified forms of tremor
|
|
333.71–333.72
|
Acquired torsion dystonia
|
|
333.79
|
Other acquired torsion dystonia
|
|
333.82
|
Orofacial dyskinesia
|
|
333.85
|
Subacute dyskinesia due to drugs
|
|
333.90
|
Unspecified extrapyramidal disease and abnormal movement disorder
|
|
333.92
|
Neuroleptic malignant syndrome
|
|
333.99
|
Other unspecified extrapyramidal disease and abnormal movement disorder (neuroleptic-induced acute akathisia)
|
|
758.0
|
Down’s Syndrome
|
|
780.09
|
Alteration of consciousness, other
|
|
780.95
|
Excessive crying of child, adolescent, or adult
|
|
780.97
|
Altered mental status
|
|
784.3
|
Aphasia
|
|
784.60–784.61
|
Other symbolic dysfunction
|
|
784.69
|
Other symbolic dysfunction
|
|
995.20
|
Unspecified adverse effect of unspecified drug, medicinal and biological substance
|
|
995.50–995.55
|
Child maltreatment syndrome
|
|
995.59
|
Child maltreatment syndrome
|
|
995.80–995.85
|
Adult maltreatment
|
|
V11.0 – V11.4
|
Personal history of mental disorder
|
|
V11.8 – V11.9
|
Personal history of mental disorder
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request.
The total number of timed minutes must be documented in the patient’s medical record.
Section I: Psychiatric Diagnostic Interview Examinations (90801, 90802)
The medical records must reflect in legible form the elements outlined in the above description of the services and contain all of the following elements:
- Date.
- Referral source.
- Length of session (these are not timed codes, however, the standard length of time is generally considered to be between 45 minutes and one hour).
- Content of session.
- Therapeutic techniques and approaches, including medications.
- Assessment of the patient’s ability to adhere to the treatment plan.
- Identity of person performing service (legible signature).
- For interactive therapy, medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques.
- For services that include an E/M component, the E/M services should be documented.
- Multiaxial diagnoses.
Section II: Psychological and Neuropsychological Testing
The medical record should include all of the following information:
- Reason for referral.
- Tests administered, scoring/interpretation and time involved.
- Present evaluation.
- Diagnosis (or suspected diagnosis that was the basis for the testing if no mental illness was found).
- Recommendations for interventions, if necessary.
- Identity of person performing service.
Section III: Psychotherapy Services
The medical record must indicate in legible form, the time spent in the psychotherapy encounter and the therapeutic maneuvers such as behavior modification, supportive interactions and interpretation of unconscious motivation that were applied to produce therapeutic change or stabilization.
All the following elements should be contained in or readily inferred from the medical record:
- Type of service (individual, group, family, interactive, etc.).
- Content of session.
- Therapeutic techniques and approaches, including medications.
- Identity of person performing service.
- For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques.
- For services that include an E/M component, the E/M services should be documented.
- Group therapy session notes can be organized according to the general session note guidelines for individual therapy appearing above, or the clinician may elect to use the following group note format:
- One group note that is common to all patients, documenting date, length of time for each session, along with key issues presented. Other group members’ names should not appear in this note.
- An additional notation or addendum to the group note, for each patient’s record commenting on that particular patient’s participation in the group process and any significant changes in patient status.
Section IV: Pharmacologic Management of Psychiatric Illness (90862, M0064)
Patient records for pharmacologic management code 90862 should include or be able to be inferred by a trained professional, in legible form, all the following information in each note:
- Date and diagnosis.
- Current symptoms and problems.
- Problems, reactions and side effects, if any, to medications and/or ECT.
- Description of optional minimal psychotherapeutic intervention, if any.
- Reasons for medication adjustments/changes or continuation.
Section V: Other Psychiatric and Psychological Services (90865, 90870)
See the general requirements at the beginning of this section.
Appendices
N/A
Utilization Guidelines
- Allowed units outlined in the table below may be billed no more than once per provider, per discipline, per date of service, per patient. The codes allowed 0 units in the column for “Allowed Units” may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP). (See CMS Change Request 5253 for additional details.)
|
|
|
|
Allowed Units
|
Physician/NPP Not Under a Therapy POC
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||
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CPT Code
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Code Description
|
Timed/
Untimed
|
PT
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OT
|
SLP
|
|
|
96110
|
Developmental test, lim
|
Untimed
|
1
|
1
|
1
|
1
|
|
96111
|
Developmental test, extend
|
Untimed
|
1
|
1
|
1
|
1
|
- Medicare will not cover more than three 90801 or 90802 (or a combination of both) per year, per beneficiary, same or different provider.
- Medicare will not cover more than one 90862 per day, per beneficiary.
- Medicare will not cover more than one M0064 per day, per beneficiary (whether the ECT provider is the beneficiary’s primary psychiatrist or not).
Notice: This LCD imposes utilization guideline limitations that support automated frequency denials. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
