Psychiatrist Services Psychiatrists may provide the following services: Diagnostic and therapeutic services that the psychiatrist is legally authorized to perform in accordance with State law and/or regulations. Electroconvulsive therapy (90870 and 90871): When the physician administers the anesthesia for the electroconvulsive seizure therapy, no separate pay- ment may be made for that service. Outpatient Mental Health Services Limitations: All covered therapeutic outpatient mental health services furnished by qualified psychiatrists are subjected to limitations; only 62.5 percent of expenses for these services are considered incurred expenses for Medi- care purposes. The limitation does not apply to a diagnostic service. Coding guidelines: Home Health services ordered by the psychiatrist: The home health service needs to be considered reasonable and necessary for the treatment of the psychiatric illness and requires the skills of a skilled nurse who has been specifically trained in providing psychiatric nursing care. This service must be provided under a plan of care to meet the beneficiary’s specific needs within accepted standards of medical practice and set up and reviewed by a psychiatrist. These services need to be for an individual who is eligible for home health services under the Medicare program and only when ordered by the physician verbally or in writing before delivery of the services. The order must include frequency and duration. CPT code 90801, Psychiatric diagnostic interview examination: Please refer to the appropriate CPT code book for the date of services provided. This procedure is described as the elicitation of a complete history, establishment of tentative diagnosis, and an evalu- ation of the patient’s ability and willingness to work to solve the patient’s mental problem. Medi- care may cover this service only once per patient at the onset of each new illness, suspected illness, or a new episode of an illness. An evaluation and management (E&M) service may be substituted for he initial interview procedure, including consultation codes (CPT 99241-99263), provided re- quired elements of the E&M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. Consultation codes do not include psychiatric treatment. CPT code 90802, Interactive psychiatric diagnostic interview examination using play equip- ment, physical devices, language interpreter, or other mechanisms of communication. Please refer to the appropriate CPT code book for the date of service provided. The examination for this code includes the same components as the psychiatric diagnosis interview examination which includes history, mental status, disposition, and other components as indicated. This code may be applied to the initial evaluation of adult patients with organic mental deficits, or who are catatonic or mute. The medical record must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels. If the patient is incapable of communication by any means this code may not be billed. Documentation needs to explain the beneficiary’s symptoms and response to treatment, or the receptive communication skills to under- stand the clinician if he/she were to use ordinary adult language for communication. CPT code 90862, Pharmacologic management, including prescription, use, and review of medi- cation with no more than minimal medical psychotherapy: Please refer to the appropriate CPT code book for the date of services provided. This code is not intended to be used for the actual administration of medication, nor is it intended to be used for observation of the patient taking an oral medication. Administration and supply of oral medication is a non-covered service. Nor is it intended to refer to a brief evaluation of the patient’s status or simple dosage adjustment of long term medication. The code refers to the in-depth management of psychopharmacologic agents which are potent medications with frequent serious side effects, and represents a very skilled aspect of patient care. M0064, A brief office visit for the sole purpose of monitoring or changing drug prescriptions used in treatment of mental, psychoneurotic, and personality disorders. This HCPCS code should be used for a lesser level of drug monitoring such as simple dosage adjustment. Based on the assignment of RVUs, the work involved is similar to CPT code 99212 and usually involves less than ten minutes of time. Medical Necessity: Medical necessity must always be supported by documentation in the patient’s record. Psychotherapy services are not covered if a review of the medical record indicates that Dementia (ICD-9 290.0, 290.20- 290.9, 331.0-331.2) has produced a severe enough cognitive defect to prevent establishment of a relation- ship with the therapist which would allow therapy to be effective. Profound mental retardation (ICD-9 318.2) is never covered for psychotherapy services. Documentation: The medical record must indicate that the patient has a psychiatric illness and/or is demonstrating emo- tional or behavioral symptoms sufficient to interfere with normal functioning and describe medical neces- sity specific to the service provided. Documentation must indicate and support face-to-face time spent in the psychotherapy encounter, describing the therapeutic interaction between the provider and the patient. Telephone calls are not billable to Medicare; this would include crises intervention calls. All documenta- tion should be complete, legible, and signed by the performing provider. 〈 Documentation for individual psychotherapy should include the patient’s capacity to participate in and benefit from psychotherapy. The estimated duration of treatment in terms of number of sessions should be specified. The medical record should document that the treatment is expected to improve the health status or function of the patient. Target symptoms, goals of therapy, response to therapy, and methods of monitoring outcome should be documented. 〈 Documentation for group psychotherapy should indicate that cognitive skills, such as behavior modifi- cation, supportive interactions, and discussion of reality were applied to produce therapeutic change. The record must document the person’s participation and an evaluation of its benefit, or lack thereof. Psychotherapy Services As part of the Medical Review Strategy for FY2002, WPS will be providing education on the appropri- ate billing of Psychotherapy services and will conduct medical reviews where indicated. Providers are encouraged to conduct a self-audit to identify any possible coverage and coding errors, and to submit a voluntary refund to Medicare Part B, if applicable. Description: “Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician estab- lishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.” (CPT, 2001, Page 319) Scope of Practice: While a variety of psychotherapeutic techniques are recognized for coverage under these codes, the ser- vices must be performed by a person licensed to perform psychotherapy services by the state in which he / she practices. Any therapeutic services billed by Clinical Psychologists under CPT psychotherapy codes that include medical evaluation and management services are not covered. Clinical Psychologists billing for services rendered in a hospital setting must personally perform these services. Services of a Clinical Social Worker are not covered when furnished to inpatients of a hospital or to inpatients of a SNF, if the services in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. Medicare Part B Coverage: 〈 Psychological Evaluation (CPT 90801) includes a history, mental status, and a disposition, and may include communication with family or other sources and the ordering and medical interpretation of laboratory or other medical diagnostic studies. It includes a complete mental status exam. The medical record must reflect the elements listed above. This service may be covered once, at the onset of an illness or suspected illness. It may be utilized for the same patient if a new episode of illness occurs after a hiatus, or an admission, or re-admission, to inpatient status due to complications of the underly- ing condition. 〈 Psychological Testing (CPT 96100) includes the administration, interpretation, and scoring of the tests mentioned in the CPT description and other medically accepted tests for evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation and other factors influencing treatment and prognosis. The medical record must indicate the presence of mental illness or signs of a mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved. Use of such tests when a mental illness is not suspected would be a screening procedure and is not covered by Medicare. Each test performed must be medically necessary, and therefore standardized batteries of tests are not acceptable. If the testing time exceeds eight hours, a report must be submitted indicating the medical necessity for this extended testing. 〈 Individual Psychotherapy codes (CPT 90804 – 90829) should be used only when the focus of treatment involves individual therapy and/or continuing medical diagnostic evaluation. Within this code range, any codes involving 75 – 80 minutes should not be routinely used. They are reserved for exceptional circumstances, which must be substantiated in the medical record. Psychotherapy codes should not be used as generic psychiatric service codes when another code, such as an E/M or pharmacological man- agement code, would be more appropriate. For Medicare coverage, these services do not include teaching grooming skills, monitoring activities of daily living, recreational therapy or social interac- tion. Oversight activities such as housing and financial management are not covered. 〈 Group Psychotherapy (CPT 90853), since it involves psychotherapy, must be led by a person who is authorized by state statute to perform the service. For Medicare Part B coverage, group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, sensory stimu- lation, eating together, cognitive stimulation, motion therapy, etc. Self-help groups or support groups without a qualified professional present are not billable. 〈 Family Psychotherapy with Patient Present (CPT 90847) is covered only when the primary purpose of such counseling is the treatment of the patient’s condition. Counseling concerned primarily with the effects of the patient’s condition on the individual being interviewed would not be reimbursable as part of the physician’s personal services to a patient. Examples of covered situations include a need to observe the patient’s interaction with family members and/or a need to assess the capability of, and assist the family members in, aiding in the management of the patient. 〈 Drug Management (CPT 90862) includes prescription, use, and review of medication with no more than minimal medical psychotherapy. This code is intended for use by the physician who is prescribing pharmacological therapy for a patient with an organic brain syndrome or whose diagnosis is in the ICD- 9 range of 290.0-319, and is being managed primarily by psychotropic drugs. Please note that in the state of Minnesota the ICD-9 code 305.1 is excluded from coverage. It may also be used for the patient whose psychotherapy is being managed by another mental health professional and the billing physician is managing the psychotropic medication. The service includes prescribing, monitoring the effect of the medication, and adjusting the dosage. Documentation must include the diagnosis for which the medication is prescribed and any pertinent signs and symptoms. CPT code 90862 cannot be billed “incident to” a physician’s service, nor is it intended to refer to a brief evaluation of the patient’s state or simple dosage adjustment of long-term medication. The code refers to the in-depth management of psychopharmacological agents which are potent medications with frequent serious side effects, and represents a very skilled aspect of patient care. HCPCS code M0064 should be used for the lesser level of drug monitoring, such as simple dosage adjustment. If the patient receives psychotherapy and drug management at the same visit, bill a code which combines both psychotherapy and E/M, such as 90805, 90807, and 90817. Drug management is included as part of that service by definition, and 90862 should not be billed separately. Medical Necessity: Medical necessity must always be supported by documentation in the patient’s record. Psychotherapy services are not covered if a review of the medical record indicates that Dementia (ICD-9 290.0, 290.20- 290.9, 331.0-331.2) has produced a severe enough cognitive defect to prevent establishment of a relation- ship with the therapist which would allow therapy to be effective. Profound mental retardation (ICD-9 318.2) is never covered for psychotherapy services. Documentation: The medical record must indicate that the patient has a psychiatric illness and/or is demonstrating emo- tional or behavioral symptoms sufficient to interfere with normal functioning and describe medical necessity specific to the service provided. Documentation must indicate and support face-to-face time spent in the Psychotherapy encounter, describing the therapeutic interaction between the provider and the patient. Telephone calls are not billable to Medicare; this would include crises intervention calls. All documentation should be complete, legible, and signed by the performing provider. 〈 Documentation for individual Psychotherapy should include the patient’s capacity to participate in and benefit from Psychotherapy. The estimated duration of treatment in terms of number of sessions should be specified. The medical record should document that the treatment is expected to improve the health status or function of the patient. Target symptoms, goals of therapy, response to therapy, and methods of monitoring outcome should be documented. 〈 Documentation for group Psychotherapy should indicate that cognitive skills, such as behavior modification, supportive interactions, and discussion of reality were applied to produce therapeutic change. The record must document the person’s participation and an evaluation of its benefit or lack thereof. Common Errors Noted in Psychotherapy Medical Reviews: In our experience, there are three categories of errors most commonly noted in psychotherapy review; Non- documentation, Non-covered services, and Not Medically Necessary services. Listed below are examples of errors we see under each category. 1. Non-documentation / Insufficient Documentation 〈 No medical records received for services billed 〈 Insufficient documentation to support level of care billed 〈 No documentation of face-to-face time spent with patient 〈 No documentation of Psychotherapy interventions used and the patient’s response to those interven- tions 〈 Billing provider’s active participation in the service rendered not clearly documented 1. Non-covered Services 〈 Unlicensed individuals performing Psychotherapy services 1. Not Medically Necessary Services 〈 No documentation of the patient’s capacity to participate in and benefit from Psychotherapy – medi- cal record does not indicate expected improvement in the health status or function of the patient Please use this information along with the educational material provided to evaluate your records. If issues are identified, please take this opportunity to make any necessary adjustments to your billing practice, including self-corrective actions, if applicable. Our goal is to educate providers in the appropri- ate billing of Psychotherapy claims, to ensure the integrity of the Medicare Trust Fund.