Outpatient Mental Health Treatment Limitation‐ FQHC
The Outpatient Mental Health Treatment Limitation (MHTL) limits Medicare’s liability to 62.5% of
covered expenses incurred for the outpatient treatment and management of mental, psychoneurotic, or
personality disorders (ICD‐9‐CM diagnosis codes 290 through 319).
Excluded from the MHTL are diagnostic procedures and medical (rather than psychiatric)
management of a disease process. Examples of the exclusions include:
1. Medication management ‐ brief office visits for the sole purpose of monitoring or changing drug
prescriptions used in the treatment of mental, psychoneurotic, or personality disorders.
2. Diagnostic services ‐ such as psychological testing or an office visit (or psychiatric consultation) to
establish a diagnosis.
3. Medical care ‐ as opposed to psychotherapy, furnished to a patient diagnosed with Alzheimer’s
disease or related disorder.
Determining the application of the MHTL prior to billing is the responsibility of each provider. FQHCs
are directed to bill all lines subject to the mental health limit with revenue code 0900 even if another
revenue code might better describe the service. The automatic claims processing system applies the
MHTL based on revenue code 0900.
Claims submitted with an ICD‐9‐CM diagnosis code 290‐319 filed without a revenue code line 0900 are
reviewed for additional information in FL 80 (Remarks section). (See Additional Information Decision
Guide on other side for specific language to use in FL 80 of the UB‐04). Claims filed with an IDC‐9‐CM
code 290‐319, without a revenue code line 0900, and without additional information in FL 80 are
returned to providers (RTP) for review and additional information. If the claim was submitted with a
billing error, correct the claim.
References
CMS Publication 100‐1, Medicare General Information, Eligibility, and Entitlement, Chapter 3,
“Deductibles, Coinsurance Amounts, and Payment Limitations,” Section 30‐30.3
CMS Publication 100‐2, Medicare Benefit Policy Manual, Chapter 13, Rural Health Clinic (RHC
and Federally Qualified Health Center (FQHC) Services, Section 100.6
CMS Publication 100‐4, Medicare Claims Processing Manual, Chapter 9, Rural Health Clinics and
Federally Qualified Health Centers, Section 60‐60.2
Code of Federal Regulations, Title 42, Public Health, Volume 2, Chapter IV, Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Section 410.155, “Outpatient Mental
Health Treatment Limitation”
Social Security Act, Section 1833 (C)
POEA0301 (08/08)
Mental Health Treatment Limitation
FQHC Additional Information Decision Guide
Question Answer Coding Guide System Function
1. Is the primary diagnosis in the ICD‐9‐ Code clinic visit with 0521‐0527 revenue code.
No. Not subject to limitation.
CM 290‐319 range (mental, Stop. System will process
psychoneurotic, or personality at standard rates.
Yes. May be subject to limitation. Proceed to Question #2.
disorders)?
Code clinic visit with 0521‐0527 revenue code.
2. Is the purpose of the visit for
Yes. Not subject to limitation. Additional information required. Enter System will process
diagnostic services (testing or visit to
“Diagnostic” in FL 80 of UB‐04. Stop. at standard rates.
establish a diagnosis)?
No. May be subject to limitation. Proceed to Question #3.
Code clinic visit with 0521‐0527 revenue code.
3. Is the purpose of the visit for
Yes. Not subject to limitation Additional information required. Enter System will process
medication management services
“Drug” in FL 80 of UB 04. Stop. at standard rates.
only?
No. May be subject to limitation. Proceed to Question #4.
Code clinic visit with 0521‐0527 revenue code.
4. Is the purpose of the visit medical
care (not psychotherapy) for a Yes. Not subject to limitation. Additional information required. Enter System will process
physiological process (Alzheimer’s, “Medical” in FL 80 of UB‐04. Stop. at standard rates.
Frontal Lobe Dementia, etc.)? No. May be subject to limitation. Proceed to Question #5.
5. Is the purpose of the visit to deliver System will apply
Yes. Subject to limitation. Use 0900 revenue code. Stop.
psychotherapy or to combine limitation.
medication management of a
System will return
psychiatric disorder with Verify diagnosis or purpose. Possible decision
No. claim until error is
psychotherapy? error. Correct error and repeat review.
corrected.