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Contractor InformationContractor NameFirst Coast Service Options, Inc.Contract Number09101Contract TypeA and B MACJurisdictionJ-NLCD Information LCD IDL33252Original ICD-9 LCD IDL33130LCD TitlePsychiatric Diagnostic Evaluation and Psychotherapy ServicesAMA CPT / ADA CDT Copyright StatementCPT only copyright 2002 - 2016 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright ? American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.JurisdictionFloridaOriginal Effective Date10/01/2015Revision Effective Date01/01/2017Revision Ending DateN/ARetirement DateN/ANotice Period Start DateN/ANotice Period End DateN/ACMS National Coverage PolicyLanguage quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:CMS Manual System, Pub. 100-01, Medicare General Information, Chapter 3, Section 30CMS Manual System, Pub. 100-04, Medicare Claims Processing, Chapter 12, Sections 120B and 210-210.1CMS Manual System, Pub. 100-04, Medicare Claims Processing, Chapter 12, Sections 160-170CMS Manual System, Pub. 100-08, Medicare Program Integrity, Chapter 3, Section 3.3.2.6- Psychotherapy NotesCMS Medicare Learning Network, March 2012, Mental Health Services (accessible at: Medicare Learning Network (MLN) Matters? Number: SE1407Coverage GuidanceCoverage Indications, Limitations, and/or Medical NecessityIndications of Coverage and/or Medical Necessity:This part of the policy has been divided into seven (7) sections addressing the following services:I. Psychiatric Diagnostic Evaluation and Psychiatric Diagnostic Evaluation with Medical ServicesII. PsychotherapyIII. Group PsychotherapyIV. Family PsychotherapyV. PsychoanalysisVI. Interactive Complexity ServicesVII. Psychotherapy for CrisisSection I: Psychiatric Diagnostic Evaluation and Psychiatric Diagnostic Evaluation with Medical Services (CPT codes 90791, 90792)A. Psychiatric Diagnostic Evaluation (CPT code 90791)A psychiatric diagnostic evaluation is an integrated biopsychosocial assessment that includes the elicitation of a complete medical history (to include past, family, and social), psychiatric history, a complete mental status exam, establishment of a tentative diagnosis, and an evaluation of the patient's ability and willingness to participate in the proposed treatment plan. Information may be obtained from the patient, other physicians, other clinicians or community providers, and/or family members or other sources. There may be overlapping of the medical and psychiatric history depending upon the problem(s).Although the emphasis, types of details, and style of a psychiatric evaluation differ from the medical evaluation, the purpose is the same: to establish effective communication with interaction of sufficient quality between provider and patient to gather accurate data in order to formulate tentative diagnoses, determine necessity, and as appropriate, initiate an effective and comprehensive treatment plan.Psychiatric diagnostic evaluations will be considered medically necessary when the patient has a psychiatric illness and /or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings, which may be suggestive of a psychiatric illness. This examination may also be medically necessary when baseline functioning is altered by suspected illness or symptoms. It is appropriate for dementia, in patients who experience a sudden and rapid change in behavior. The psychiatric diagnostic evaluation is not considered to be medically reasonable and necessary: ?when it is rendered to a patient who has a medical/neurological condition such as dementia, delirium, or other psychiatric conditions, which have produced a severe enough cognitive defect to prevent effective communication and the ability to assess the patient; or ?when the patient has a previously established diagnosis of a neurological condition or dementia and is not amenable to the evaluation and therapy, unless there has been an acute and/or marked mental status change, a request for second opinion, or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable; or?when a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed. Routine performance of additional psychiatric diagnostic evaluation of patients with chronic conditions is not considered medically necessary.A psychiatric diagnostic evaluation can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable. B. Psychiatric Diagnostic Evaluation with Medical Services (CPT code 90792)A psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history (to include past, family, and social), psychiatric history, a complete mental status exam, other physical examination elements as indicated, establishment of a tentative diagnosis, and an evaluation of the patient's ability and willingness to participate in the proposed treatment plan. The evaluation may include communication with family members or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.When a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed. Routine performance of additional psychiatric diagnostic evaluation of patients with chronic conditions is not considered medically necessary.A psychiatric diagnostic evaluation with medical services can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation with medical services may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.Section II: Psychotherapy (CPT Codes 90832-90838)Psychotherapy is the treatment of mental illness and behavior disturbances, in which the provider establishes a professional contact with the patient and through therapeutic communication and techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, facilitate coping mechanisms and/or encourage personality growth and development.Insight oriented, behavior modifying, and/or supportive psychotherapy refers to the development of insight or affective understanding, the use of behavior modification techniques, the use of supportive interactions, and the use of cognitive discussion of reality, or any combination of the above to provide therapeutic change.Psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning. Psychotherapy services must be performed by a person licensed by the state where practicing, and whose training and scope of practice allow that person to perform such services. Psychotherapy must be provided as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnoses. Some patients receive psychotherapy alone, and others receive psychotherapy along with medical evaluation and management services. These services involve a variety of responsibilities unique to the medical management of psychiatric patients such as medical diagnostic evaluation (i.e. evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug management when indicated, physician orders, interpretation of laboratory or other diagnostic studies and observations. The patient should be amenable to allowing insight-oriented therapy such as behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy, and cognitive/behavioral techniques to be effective.Psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication with interaction of sufficient quality to allow insight oriented therapy (i.e. behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy or cognitive/behavioral techniques). In these cases, evaluation and management or pharmacological codes should be used.Psychotherapy services are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art play), or social interaction.Psychotherapy times are for face-to-face services with the patient. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.Some psychiatric patients receive a medical evaluation and management service on the same day as a psychotherapy service by the same physician or other qualified health care professional. These services to be medically necessary should be significantly different and separately identifiable.Section III: Group Psychotherapy (CPT Code 90853)Group Psychotherapy is a form of treatment administered in a group setting with a trained group leader in charge of several patients. Since it involves psychotherapy it must be led by a person, authorized by state statute to perform this service. This will usually mean a psychiatrist, clinical psychologist, licensed clinical social worker, certified nurse practitioner, or clinical nurse specialist. The group is a carefully selected group of patients meeting for a prescribed period of time during which common issues are presented and generally relate to and evolve towards a therapeutic goal. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional outpouring, instruction, and support. Medical diagnostic evaluation and pharmacological management may continue by a physician when indicated. The group size should be of a size that can be considered therapeutically successful (i.e., maximum 12 people). Group therapy will be considered medically necessary when the patient has a psychiatric illness and /or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings. The issues presented and explored in the group setting should evolve towards a theme or a therapeutic goal. Group psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis. This treatment plan must be adhered to and should be endorsed and monitored by the treating physician or physician of record. The specialized skills of a mental health care professional must be required. Group psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium, or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication including interaction of sufficient quality with the therapist and members of the group. Other services such as music therapy, socialization, recreational activities/recreational therapy, art classes/art therapy, excursions, sensory stimulation, eating together, cognitive stimulation, or motion therapy are not considered to be medically reasonable and necessary.Section IV: Family Psychotherapy (CPT Codes 90846, 90847)Family Psychotherapy is a specialized therapeutic technique for treating the identified patients’ mental illness by intervening in a family system in such a way as to modify the family structure, dynamics, and interactions which exert influence on the patient’s emotions and behaviors.Family psychotherapy sessions may occur with or without the patient present. The process of family psychotherapy helps reveal a family’s repetitious communication patterns that are sustaining and reflecting the identified patient’s behavior. For the purposes of this policy, a family member is any individual who spends a significant amount of the time with the patient and provides psychological support to the patient, which may include but is not limited to a caregiver or significant other. Family psychotherapy will be considered medically reasonable and necessary only in clinically appropriate circumstances and when the primary purpose of such psychotherapy is the treatment/management of the patient’s condition. Examples are as follows: ?when there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members; and/or?where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapeutic techniques, the family members in the management of the patient.Family psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis.Family psychotherapy must be conducted face to face by physicians (MD/DO), psychologists, or other mental health professionals licensed or authorized by state statutes and considered eligible for reimbursement.Family psychotherapy is considered to be medically reasonable and necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning. In certain types of medical conditions, such as the unconscious or comatose patient, family psychotherapy would not be medically reasonable or necessary. Also, CPT code 90849 (Multiple family group psychotherapy) would not be considered treatment directly related to the patient’s care and therefore would not be considered medically necessary.A family psychotherapy session generally lasts for at least 45-50 minutes.Section V: Psychoanalysis (CPT Code 90845)Psychoanalysis is a treatment modality that uses psychoanalytic theories as the frame for formulation and understanding of the therapy process. These theories provide a focus on increasing self-understanding and deepening insight into emotional issues and conflicts which underlie presenting emotional difficulties. Typically therapists make use of exploration of unconscious thoughts and feelings which may relate to underlying emotional conflicts, interpretation of defensive processes which obstruct emotional awareness, and consideration of issues related to sense of self-esteem.Psychoanalysis uses a special technique to gain insight into a patient's unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.The medical record must document the indications for psychoanalysis, description of the transference, and that psychoanalytic techniques were used. The physician using this technique must be trained and credentialed in its use. Clinical nurse specialists (CNS) and nurse practitioners (NP) are not eligible for payment for psychoanalysis. It is not a time-related code, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved. Psychoanalysis is generally considered unsuitable for psychoses.Section VI: Interactive Complexity Services (CPT Code 90785)Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients. The interactive complexity techniques are utilized primarily to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. In the aforementioned instances, it involves the use of physical aids and nonverbal communication to overcome barriers to the therapeutic interaction between the clinician and the patient who has not yet developed or has lost either the expressive language communication skills to explain his/her symptoms and response to treatment or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. An interactive technique may include the use of inanimate objects such as toys and dolls for a child, physical aids, and non-verbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or in situations where the patient does not speak the same language as the provider of care. If a patient is unable to communicate by any means, the interactive complexity codes should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792), psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350), and group psychotherapy (90853). Interactive complexity may be reported with psychotherapy when at least one of the following communication factors is present during the visit:? The need to manage maladaptive communication among participants (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) that complicates delivery of care.? Caregiver emotions or behaviors that interfere with implementation of the treatment plan.? Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.? Use of play equipment, physical devices, interpreter, or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or has lost expressive or receptive language skills to use or understand typical language.Section VII: Psychotherapy for Crisis (CPT Codes 90839-90840)Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to a patient with high distress. The crisis codes are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service.Coding InformationBill Type CodesContractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.12Hospital Inpatient (Medicare Part B only)13Hospital Outpatient22Skilled Nursing - Inpatient (Medicare Part B only)23Skilled Nursing - Outpatient71Clinic - Rural Health75Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)76Clinic - Community Mental Health Center77Clinic - Federally Qualified Health Center (FQHC)85Critical Access HospitalRevenue CodesContractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.CodeDescription0250Pharmacy - General Classification0900Behavioral Health Treatment/Services - General Classification0914Behavioral Health Treatment/Services - Individual Therapy0915Behavioral Health Treatment/Services - Group Therapy0916Behavioral Health Treatment/Services - Family TherapyCPT/HCPCS CodesGroup 1 ParagraphN/AGroup 1 Codes90785Psytx complex interactive90791Psych diagnostic evaluation90792Psych diag eval w/med srvcs90832Psytx w pt 30 minutes90833Psytx w pt w e/m 30 min90834Psytx w pt 45 minutes90836Psytx w pt w e/m 45 min90837Psytx w pt 60 minutes90838Psytx w pt w e/m 60 min90839Psytx crisis initial 60 min90840Psytx crisis ea addl 30 min90845Psychoanalysis90846Family psytx w/o pt 50 min90847Family psytx w/pt 50 min90853Group psychotherapyICD-9 Codes that Support Medical NecessityN/AICD-9 Codes that DO NOT Support Medical NecessityN/AICD-10 Codes that Support Medical NecessityGroup 1 ParagraphN/AGroup 1 CodesF01.51Vascular dementia with behavioral disturbanceF02.80Dementia in other diseases classified elsewhere without behavioral disturbanceF02.81Dementia in other diseases classified elsewhere with behavioral disturbanceF03.90Unspecified dementia without behavioral disturbanceF03.91Unspecified dementia with behavioral disturbanceF04Amnestic disorder due to known physiological conditionF05Delirium due to known physiological conditionF06.0Psychotic disorder with hallucinations due to known physiological conditionF06.1Catatonic disorder due to known physiological conditionF06.30Mood disorder due to known physiological condition, unspecifiedF06.31Mood disorder due to known physiological condition with depressive featuresF06.32Mood disorder due to known physiological condition with major depressive-like episodeF06.33Mood disorder due to known physiological condition with manic featuresF06.34Mood disorder due to known physiological condition with mixed featuresF06.4Anxiety disorder due to known physiological conditionF06.8Other specified mental disorders due to known physiological conditionF07.0Personality change due to known physiological conditionF07.81Postconcussional syndromeF07.89Other personality and behavioral disorders due to known physiological conditionF07.9Unspecified personality and behavioral disorder due to known physiological conditionF09Unspecified mental disorder due to known physiological conditionF10.10Alcohol abuse, uncomplicatedF10.120Alcohol abuse with intoxication, uncomplicatedF10.121Alcohol abuse with intoxication deliriumF10.129Alcohol abuse with intoxication, unspecifiedF10.14Alcohol abuse with alcohol-induced mood disorderF10.150Alcohol abuse with alcohol-induced psychotic disorder with delusionsF10.151Alcohol abuse with alcohol-induced psychotic disorder with hallucinationsF10.159Alcohol abuse with alcohol-induced psychotic disorder, unspecifiedF10.180Alcohol abuse with alcohol-induced anxiety disorderF10.181Alcohol abuse with alcohol-induced sexual dysfunctionF10.182Alcohol abuse with alcohol-induced sleep disorderF10.188Alcohol abuse with other alcohol-induced disorderF10.19Alcohol abuse with unspecified alcohol-induced disorderF10.20Alcohol dependence, uncomplicatedF10.21Alcohol dependence, in remissionF10.220Alcohol dependence with intoxication, uncomplicatedF10.221Alcohol dependence with intoxication deliriumF10.229Alcohol dependence with intoxication, unspecifiedF11.10Opioid abuse, uncomplicatedF11.120Opioid abuse with intoxication, uncomplicatedF11.129Opioid abuse with intoxication, unspecifiedF11.20Opioid dependence, uncomplicatedF11.21Opioid dependence, in remissionF11.220Opioid dependence with intoxication, uncomplicatedF11.221Opioid dependence with intoxication deliriumF11.222Opioid dependence with intoxication with perceptual disturbanceF11.229Opioid dependence with intoxication, unspecifiedF11.23Opioid dependence with withdrawalF11.24Opioid dependence with opioid-induced mood disorderF11.250Opioid dependence with opioid-induced psychotic disorder with delusionsF11.251Opioid dependence with opioid-induced psychotic disorder with hallucinationsF11.259Opioid dependence with opioid-induced psychotic disorder, unspecifiedF11.281Opioid dependence with opioid-induced sexual dysfunctionF11.282Opioid dependence with opioid-induced sleep disorderF11.288Opioid dependence with other opioid-induced disorderF11.29Opioid dependence with unspecified opioid-induced disorderF11.90Opioid use, unspecified, uncomplicatedF12.10Cannabis abuse, uncomplicatedF12.20Cannabis dependence, uncomplicatedF12.21Cannabis dependence, in remissionF12.220Cannabis dependence with intoxication, uncomplicatedF12.221Cannabis dependence with intoxication deliriumF12.222Cannabis dependence with intoxication with perceptual disturbanceF12.229Cannabis dependence with intoxication, unspecifiedF12.250Cannabis dependence with psychotic disorder with delusionsF12.251Cannabis dependence with psychotic disorder with hallucinationsF12.259Cannabis dependence with psychotic disorder, unspecifiedF12.280Cannabis dependence with cannabis-induced anxiety disorderF12.288Cannabis dependence with other cannabis-induced disorderF12.29Cannabis dependence with unspecified cannabis-induced disorderF12.90Cannabis use, unspecified, uncomplicatedF13.10Sedative, hypnotic or anxiolytic abuse, uncomplicatedF13.120Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicatedF13.20Sedative, hypnotic or anxiolytic dependence, uncomplicatedF13.21Sedative, hypnotic or anxiolytic dependence, in remissionF13.220Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicatedF13.221Sedative, hypnotic or anxiolytic dependence with intoxication deliriumF13.229Sedative, hypnotic or anxiolytic dependence with intoxication, unspecifiedF13.230Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicatedF13.231Sedative, hypnotic or anxiolytic dependence with withdrawal deliriumF13.232Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbanceF13.239Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecifiedF13.24Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorderF13.250Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusionsF13.251Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinationsF13.259Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecifiedF13.26Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorderF13.27Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementiaF13.280Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorderF13.281Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunctionF13.282Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorderF13.288Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorderF13.29Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorderF13.90Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicatedF14.10Cocaine abuse, uncomplicatedF14.120Cocaine abuse with intoxication, uncomplicatedF14.20Cocaine dependence, uncomplicatedF14.21Cocaine dependence, in remissionF14.220Cocaine dependence with intoxication, uncomplicatedF14.221Cocaine dependence with intoxication deliriumF14.222Cocaine dependence with intoxication with perceptual disturbanceF14.229Cocaine dependence with intoxication, unspecifiedF14.23Cocaine dependence with withdrawalF14.24Cocaine dependence with cocaine-induced mood disorderF14.250Cocaine dependence with cocaine-induced psychotic disorder with delusionsF14.251Cocaine dependence with cocaine-induced psychotic disorder with hallucinationsF14.259Cocaine dependence with cocaine-induced psychotic disorder, unspecifiedF14.280Cocaine dependence with cocaine-induced anxiety disorderF14.281Cocaine dependence with cocaine-induced sexual dysfunctionF14.282Cocaine dependence with cocaine-induced sleep disorderF14.288Cocaine dependence with other cocaine-induced disorderF14.29Cocaine dependence with unspecified cocaine-induced disorderF14.90Cocaine use, unspecified, uncomplicatedF15.10Other stimulant abuse, uncomplicatedF15.120Other stimulant abuse with intoxication, uncomplicatedF15.20Other stimulant dependence, uncomplicatedF15.21Other stimulant dependence, in remissionF15.220Other stimulant dependence with intoxication, uncomplicatedF15.221Other stimulant dependence with intoxication deliriumF15.222Other stimulant dependence with intoxication with perceptual disturbanceF15.229Other stimulant dependence with intoxication, unspecifiedF15.23Other stimulant dependence with withdrawalF15.24Other stimulant dependence with stimulant-induced mood disorderF15.250Other stimulant dependence with stimulant-induced psychotic disorder with delusionsF15.251Other stimulant dependence with stimulant-induced psychotic disorder with hallucinationsF15.259Other stimulant dependence with stimulant-induced psychotic disorder, unspecifiedF15.280Other stimulant dependence with stimulant-induced anxiety disorderF15.281Other stimulant dependence with stimulant-induced sexual dysfunctionF15.282Other stimulant dependence with stimulant-induced sleep disorderF15.288Other stimulant dependence with other stimulant-induced disorderF15.29Other stimulant dependence with unspecified stimulant-induced disorderF15.90Other stimulant use, unspecified, uncomplicatedF16.10Hallucinogen abuse, uncomplicatedF16.120Hallucinogen abuse with intoxication, uncomplicatedF16.20Hallucinogen dependence, uncomplicatedF16.21Hallucinogen dependence, in remissionF16.220Hallucinogen dependence with intoxication, uncomplicatedF16.221Hallucinogen dependence with intoxication with deliriumF16.229Hallucinogen dependence with intoxication, unspecifiedF16.24Hallucinogen dependence with hallucinogen-induced mood disorderF16.250Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusionsF16.251Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinationsF16.259Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecifiedF16.280Hallucinogen dependence with hallucinogen-induced anxiety disorderF16.283Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks)F16.288Hallucinogen dependence with other hallucinogen-induced disorderF16.29Hallucinogen dependence with unspecified hallucinogen-induced disorderF16.90Hallucinogen use, unspecified, uncomplicatedF17.200Nicotine dependence, unspecified, uncomplicatedF17.201Nicotine dependence, unspecified, in remissionF17.210Nicotine dependence, cigarettes, uncomplicatedF17.211Nicotine dependence, cigarettes, in remissionF17.220Nicotine dependence, chewing tobacco, uncomplicatedF17.221Nicotine dependence, chewing tobacco, in remissionF17.290Nicotine dependence, other tobacco product, uncomplicatedF17.291Nicotine dependence, other tobacco product, in remissionF18.10Inhalant abuse, uncomplicatedF18.120Inhalant abuse with intoxication, uncomplicatedF18.20Inhalant dependence, uncomplicatedF18.21Inhalant dependence, in remissionF18.220Inhalant dependence with intoxication, uncomplicatedF18.221Inhalant dependence with intoxication deliriumF18.229Inhalant dependence with intoxication, unspecifiedF18.24Inhalant dependence with inhalant-induced mood disorderF18.250Inhalant dependence with inhalant-induced psychotic disorder with delusionsF18.251Inhalant dependence with inhalant-induced psychotic disorder with hallucinationsF18.259Inhalant dependence with inhalant-induced psychotic disorder, unspecifiedF18.27Inhalant dependence with inhalant-induced dementiaF18.280Inhalant dependence with inhalant-induced anxiety disorderF18.288Inhalant dependence with other inhalant-induced disorderF18.29Inhalant dependence with unspecified inhalant-induced disorderF18.90Inhalant use, unspecified, uncomplicatedF19.10Other psychoactive substance abuse, uncomplicatedF19.120Other psychoactive substance abuse with intoxication, uncomplicatedF19.20Other psychoactive substance dependence, uncomplicatedF19.21Other psychoactive substance dependence, in remissionF19.220Other psychoactive substance dependence with intoxication, uncomplicatedF19.221Other psychoactive substance dependence with intoxication deliriumF19.222Other psychoactive substance dependence with intoxication with perceptual disturbanceF19.229Other psychoactive substance dependence with intoxication, unspecifiedF19.230Other psychoactive substance dependence with withdrawal, uncomplicatedF19.231Other psychoactive substance dependence with withdrawal deliriumF19.232Other psychoactive substance dependence with withdrawal with perceptual disturbanceF19.239Other psychoactive substance dependence with withdrawal, unspecifiedF19.24Other psychoactive substance dependence with psychoactive substance-induced mood disorderF19.250Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusionsF19.251Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinationsF19.259Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, unspecifiedF19.26Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorderF19.27Other psychoactive substance dependence with psychoactive substance-induced persisting dementiaF19.280Other psychoactive substance dependence with psychoactive substance-induced anxiety disorderF19.281Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunctionF19.282Other psychoactive substance dependence with psychoactive substance-induced sleep disorderF19.288Other psychoactive substance dependence with other psychoactive substance-induced disorderF19.29Other psychoactive substance dependence with unspecified psychoactive substance-induced disorderF19.90Other psychoactive substance use, unspecified, uncomplicatedF20.0Paranoid schizophreniaF20.1Disorganized schizophreniaF20.2Catatonic schizophreniaF20.3Undifferentiated schizophreniaF20.5Residual schizophreniaF20.81Schizophreniform disorderF20.89Other schizophreniaF21Schizotypal disorderF22Delusional disordersF23Brief psychotic disorderF24Shared psychotic disorderF25.0Schizoaffective disorder, bipolar typeF25.1Schizoaffective disorder, depressive typeF25.8Other schizoaffective disordersF30.10Manic episode without psychotic symptoms, unspecifiedF30.11Manic episode without psychotic symptoms, mildF30.12Manic episode without psychotic symptoms, moderateF30.13Manic episode, severe, without psychotic symptomsF30.2Manic episode, severe with psychotic symptomsF30.3Manic episode in partial remissionF30.4Manic episode in full remissionF30.8Other manic episodesF31.0Bipolar disorder, current episode hypomanicF31.10Bipolar disorder, current episode manic without psychotic features, unspecifiedF31.11Bipolar disorder, current episode manic without psychotic features, mildF31.12Bipolar disorder, current episode manic without psychotic features, moderateF31.13Bipolar disorder, current episode manic without psychotic features, severeF31.2Bipolar disorder, current episode manic severe with psychotic featuresF31.30Bipolar disorder, current episode depressed, mild or moderate severity, unspecifiedF31.31Bipolar disorder, current episode depressed, mildF31.32Bipolar disorder, current episode depressed, moderateF31.4Bipolar disorder, current episode depressed, severe, without psychotic featuresF31.5Bipolar disorder, current episode depressed, severe, with psychotic featuresF31.60Bipolar disorder, current episode mixed, unspecifiedF31.61Bipolar disorder, current episode mixed, mildF31.62Bipolar disorder, current episode mixed, moderateF31.63Bipolar disorder, current episode mixed, severe, without psychotic featuresF31.64Bipolar disorder, current episode mixed, severe, with psychotic featuresF31.81Bipolar II disorderF31.89Other bipolar disorderF32.0Major depressive disorder, single episode, mildF32.1Major depressive disorder, single episode, moderateF32.2Major depressive disorder, single episode, severe without psychotic featuresF32.3Major depressive disorder, single episode, severe with psychotic featuresF32.4Major depressive disorder, single episode, in partial remissionF32.5Major depressive disorder, single episode, in full remissionF32.81Premenstrual dysphoric disorderF32.89Other specified depressive episodesF33.0Major depressive disorder, recurrent, mildF33.1Major depressive disorder, recurrent, moderateF33.2Major depressive disorder, recurrent severe without psychotic featuresF33.3Major depressive disorder, recurrent, severe with psychotic symptomsF33.40Major depressive disorder, recurrent, in remission, unspecifiedF33.41Major depressive disorder, recurrent, in partial remissionF33.42Major depressive disorder, recurrent, in full remissionF33.8Other recurrent depressive disordersF34.0Cyclothymic disorderF34.1Dysthymic disorderF34.81Disruptive mood dysregulation disorderF34.89Other specified persistent mood disordersF40.01Agoraphobia with panic disorderF40.02Agoraphobia without panic disorderF40.10Social phobia, unspecifiedF40.11Social phobia, generalizedF40.210ArachnophobiaF40.218Other animal type phobiaF40.220Fear of thunderstormsF40.228Other natural environment type phobiaF40.230Fear of bloodF40.231Fear of injections and transfusionsF40.232Fear of other medical careF40.233Fear of injuryF40.240ClaustrophobiaF40.241AcrophobiaF40.242Fear of bridgesF40.243Fear of flyingF40.248Other situational type phobiaF40.290AndrophobiaF40.291GynephobiaF40.298Other specified phobiaF40.8Other phobic anxiety disordersF41.0Panic disorder [episodic paroxysmal anxiety] without agoraphobiaF41.1Generalized anxiety disorderF41.3Other mixed anxiety disordersF41.8Other specified anxiety disordersF42.2Mixed obsessional thoughts and actsF42.3Hoarding disorderF42.4Excoriation (skin-picking) disorderF42.8Other obsessive-compulsive disorderF42.9Obsessive-compulsive disorder, unspecifiedF43.0Acute stress reactionF43.10Post-traumatic stress disorder, unspecifiedF43.11Post-traumatic stress disorder, acuteF43.12Post-traumatic stress disorder, chronicF43.20Adjustment disorder, unspecifiedF43.21Adjustment disorder with depressed moodF43.22Adjustment disorder with anxietyF43.23Adjustment disorder with mixed anxiety and depressed moodF43.24Adjustment disorder with disturbance of conductF43.25Adjustment disorder with mixed disturbance of emotions and conductF43.29Adjustment disorder with other symptomsF43.8Other reactions to severe stressF44.0Dissociative amnesiaF44.1Dissociative fugueF44.2Dissociative stuporF44.4Conversion disorder with motor symptom or deficitF44.5Conversion disorder with seizures or convulsionsF44.6Conversion disorder with sensory symptom or deficitF44.7Conversion disorder with mixed symptom presentationF44.81Dissociative identity disorderF44.89Other dissociative and conversion disordersF45.0Somatization disorderF45.1Undifferentiated somatoform disorderF45.20Hypochondriacal disorder, unspecifiedF45.21HypochondriasisF45.22Body dysmorphic disorderF45.29Other hypochondriacal disordersF45.41Pain disorder exclusively related to psychological factorsF45.42Pain disorder with related psychological factorsF45.8Other somatoform disordersF48.1Depersonalization-derealization syndromeF48.2Pseudobulbar affectF48.8Other specified nonpsychotic mental disordersF50.00Anorexia nervosa, unspecifiedF50.01Anorexia nervosa, restricting typeF50.02Anorexia nervosa, binge eating/purging typeF50.2Bulimia nervosaF50.81Binge eating disorderF50.89Other specified eating disorderF51.01Primary insomniaF51.02Adjustment insomniaF51.03Paradoxical insomniaF51.04Psychophysiologic insomniaF51.05Insomnia due to other mental disorderF51.09Other insomnia not due to a substance or known physiological conditionF51.11Primary hypersomniaF51.12Insufficient sleep syndromeF51.13Hypersomnia due to other mental disorderF51.19Other hypersomnia not due to a substance or known physiological conditionF51.3Sleepwalking [somnambulism]F51.4Sleep terrors [night terrors]F51.5Nightmare disorderF51.8Other sleep disorders not due to a substance or known physiological conditionF52.0Hypoactive sexual desire disorderF52.1Sexual aversion disorderF52.21Male erectile disorderF52.22Female sexual arousal disorderF52.31Female orgasmic disorderF52.32Male orgasmic disorderF52.4Premature ejaculationF52.5Vaginismus not due to a substance or known physiological conditionF52.6Dyspareunia not due to a substance or known physiological conditionF52.8Other sexual dysfunction not due to a substance or known physiological conditionF53Puerperal psychosisF54Psychological and behavioral factors associated with disorders or diseases classified elsewhereF55.0Abuse of antacidsF55.1Abuse of herbal or folk remediesF55.2Abuse of laxativesF55.3Abuse of steroids or hormonesF55.4Abuse of vitaminsF55.8Abuse of other non-psychoactive substancesF59Unspecified behavioral syndromes associated with physiological disturbances and physical factorsF60.0Paranoid personality disorderF60.1Schizoid personality disorderF60.2Antisocial personality disorderF60.3Borderline personality disorderF60.4Histrionic personality disorderF60.5Obsessive-compulsive personality disorderF60.6Avoidant personality disorderF60.7Dependent personality disorderF60.81Narcissistic personality disorderF60.89Other specific personality disordersF60.9Personality disorder, unspecifiedF63.0Pathological gamblingF63.1PyromaniaF63.2KleptomaniaF63.3TrichotillomaniaF63.81Intermittent explosive disorderF63.89Other impulse disordersF63.9Impulse disorder, unspecifiedF64.0TranssexualismF64.1Dual role transvestismF64.2Gender identity disorder of childhoodF64.8Other gender identity disordersF64.9Gender identity disorder, unspecifiedF65.0FetishismF65.1Transvestic fetishismF65.2ExhibitionismF65.3VoyeurismF65.4PedophiliaF65.50Sadomasochism, unspecifiedF65.51Sexual masochismF65.52Sexual sadismF65.81FrotteurismF65.89Other paraphiliasF65.9Paraphilia, unspecifiedF66Other sexual disordersF68.10Factitious disorder, unspecifiedF68.11Factitious disorder with predominantly psychological signs and symptomsF68.12Factitious disorder with predominantly physical signs and symptomsF68.13Factitious disorder with combined psychological and physical signs and symptomsF68.8Other specified disorders of adult personality and behaviorF69Unspecified disorder of adult personality and behaviorF70Mild intellectual disabilitiesF71Moderate intellectual disabilitiesF72Severe intellectual disabilitiesF73Profound intellectual disabilitiesF80.0Phonological disorderF80.1Expressive language disorderF80.2Mixed receptive-expressive language disorderF80.4Speech and language development delay due to hearing lossF80.81Childhood onset fluency disorderF80.82Social pragmatic communication disorderF80.89Other developmental disorders of speech and languageF80.9Developmental disorder of speech and language, unspecifiedF81.0Specific reading disorderF81.2Mathematics disorderF81.81Disorder of written expressionF81.89Other developmental disorders of scholastic skillsF81.9Developmental disorder of scholastic skills, unspecifiedF82Specific developmental disorder of motor functionF88Other disorders of psychological developmentF89Unspecified disorder of psychological developmentF90.0Attention-deficit hyperactivity disorder, predominantly inattentive typeF90.1Attention-deficit hyperactivity disorder, predominantly hyperactive typeF90.2Attention-deficit hyperactivity disorder, combined typeF90.8Attention-deficit hyperactivity disorder, other typeF90.9Attention-deficit hyperactivity disorder, unspecified typeF91.0Conduct disorder confined to family contextF91.1Conduct disorder, childhood-onset typeF91.2Conduct disorder, adolescent-onset typeF91.3Oppositional defiant disorderF91.8Other conduct disordersF91.9Conduct disorder, unspecifiedF93.0Separation anxiety disorder of childhoodF93.8Other childhood emotional disordersF93.9Childhood emotional disorder, unspecifiedF94.0Selective mutismF94.1Reactive attachment disorder of childhoodF94.2Disinhibited attachment disorder of childhoodF94.8Other childhood disorders of social functioningF94.9Childhood disorder of social functioning, unspecifiedF95.0Transient tic disorderF95.1Chronic motor or vocal tic disorderF95.2Tourette's disorderF95.8Other tic disordersF95.9Tic disorder, unspecifiedF98.0Enuresis not due to a substance or known physiological conditionF98.1Encopresis not due to a substance or known physiological conditionF98.21Rumination disorder of infancyF98.29Other feeding disorders of infancy and early childhoodF98.3Pica of infancy and childhoodF98.4Stereotyped movement disordersF98.5Adult onset fluency disorderF98.8Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescenceF98.9Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescenceF99Mental disorder, not otherwise specifiedG30.0Alzheimer's disease with early onsetG30.1Alzheimer's disease with late onsetG30.8Other Alzheimer's diseaseG30.9Alzheimer's disease, unspecifiedZ01.818Encounter for other preprocedural examinationICD-10 Codes that DO NOT Support Medical NecessityN/AGeneral InformationAssociated InformationDocumentation RequirementsThe following section addresses the documentation requirements that support indications of coverage and/or medical necessity:The patient’s medical record must contain documentation that clearly supports the medical necessity for services included within this LCD. (See “Indications and Limitations of Coverage and/or Medical Necessity” section.)The medical record for psychiatric diagnostic evaluation with or without medical assessment (CPT codes 90791, 90792) should indicate the presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms which may be suggestive of a psychiatric illness or are sufficient to significantly alter baseline functioning. The diagnostic evaluation should include:?The reason for the evaluation/patient’s chief complaint ?A referral source (if applicable)?History of present illness, including length of existence of problems/symptoms/conditions?Past history (psychiatric)?Significant medical history and current medications?Social history?Family history?Mental status exam?Strengths/liabilities?Multi-axis diagnosis or diagnostic impression list-including problem list ?Treatment plan (including methods of therapy, anticipated length of treatment to the extent possible, and a description of the planned measurable and objective goals related to expected changes in behavior or thought processes)In circumstances where other informants (family or other sources) are interviewed in lieu of the patient, documentation must include the elements outlined previously, as well as the specific reason(s) for not evaluating the patient. Any notations where family members provided patient history should be included. This should be a rare occurrence.Note: If a psychiatric diagnostic evaluation with medical assessment is performed, the physician or NPP may use CPT code 90792 or an evaluation and management (E/M) code. If an E/M code is chosen, refer to the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services accessible at documentation for interactive complexity services (CPT code add-on code 90785) must clearly reflect the requirements of the corresponding non-interactive procedure codes. Documentation to support the medical necessity for an interactive complexity procedure code should be in addition to these guidelines. Any time that an interactive complexity service is reported, the medical record must clearly support the rationale for this approach. Otherwise stated, there must be an explanation of what specific communication factors complicated the delivery of a psychiatric procedure. The medical record must indicate that the person being evaluated has one of the following communication factors present during the visit:?The need to manage maladaptive communication among participants (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) that complicates delivery of care.? Caregiver emotions or behaviors that interfere with implementation of the treatment plan.? Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.? Use of play equipment, physical devices, interpreter, or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or has lost expressive or receptive language skills to use or understand typical language.Additionally, the medical record must include adaptations utilized in the session to overcome the difficulty in communication and the rationale for employing these techniques justifying the interactive complexity of the service. When billed in conjunction with time based codes, the documentation must indicate the amount of time spent in providing interactive complexity services. The medical record must include treatment recommendations.The documentation for psychotherapy for crisis (CPT codes 90839, 90840) must clearly support that for any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service. These are time-based codes and are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. Do not report with CPT codes 90791 or 90792. The documentation for psychoanalysis or psychotherapy services including group and family psychotherapy (CPT codes 90832-90838, 90845, 90846, 90847, and 90853) should include on a periodic basis the patient’s capacity to participate and benefit from psychotherapy/psychoanalysis. Such periodic documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, measurable and objective goals of therapy related to changes in behavior, thought processes and/or medications, methods of monitoring outcome, and why the chosen therapy is an appropriate modality either in lieu of or in addition to another form of psychiatric treatment. For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient. For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected. Documentation will reflect adjustments in the treatment plan that reveals the dynamics of treatment. Psychotherapy/psychoanalysis services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication with interaction of sufficient quality to allow insight oriented therapy.It is expected that the treatment plan for a patient receiving outpatient psychotherapy or psychoanalysis services, (i.e., measurable and objective treatment goals, descriptive documentation of therapeutic intervention, frequency of sessions, and estimated duration of treatment) will be updated on a periodic basis, generally at least every three months.For services billed as CPT codes 90832-90838, 90853, and 90845, the medical record documentation maintained by the provider must indicate the medical necessity of each psychotherapy/psychoanalysis session and include the following: ? Psychotherapy services (CPT codes 90832-90838) are time based codes. Start and stop times must be documented for CPT codes 90832, 90834, and 90837. For psychotherapy services performed with an evaluation and management (E/M) service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not be continuous in a combined psychotherapy with an E/M service. However, since psychotherapy is a time-based code, the expectation would be documentation of the start and stop time of the psychotherapy with an E/M service and documentation of the total minutes devoted to psychotherapy. The total time does not include the E/M time. Also note that when psychotherapy is performed with an E/M by the same physician or NPP, the documentation should show that they are separately identifiable services. Psychotherapy times are for face-to-face services with the patient. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.Some psychiatric patients receive a medical evaluation and management service on the same day as a psychotherapy service by the same physician or other qualified health care professional. These services to be medically necessary should be significantly different and separately identifiable.Prolonged services may not be reported when psychotherapy services billed with an E/M service (i.e., add-on codes 90833, 90836, 90838) are reported. For code 90837 (psychotherapy, 60 minutes with patient, a physician or other qualified health care professional can report a prolonged service code if the psychotherapy service, not performed with an E/M service, is 90 minutes or longer involving direct patient contact.If psychotherapy codes are billed incident-to, all incident-to rules must be met, and the person providing the psychotherapy service must be licensed in the state to perform psychotherapy.?The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning; and?A detailed summary of the session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and?The degree of patient participation and interaction with the therapist, the reaction of the patient to the therapy session, documentation toward goal oriented outcomes and the changes or lack of changes in patient symptoms and/or behavior as a result of the therapy session.?The rationale for any departure from the plan or extension of therapy should be documented in the medical record. The therapist must document patient/therapist interaction in addition to an assessment of the patient’s problem(s).Additionally, for psychoanalysis (CPT code 90845), the medical record must document the indications for psychoanalysis, description of the transference, and that psychoanalytic techniques were used. The physician using this technique must be trained and credentialed in its use. CNS’s and NP’s are not eligible for payment for psychoanalysis. It is not time-related, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved.For family psychotherapy services (with or without the patient present) billed as CPT code 90846 or 90847, the medical record documentation maintained by the provider must indicate the medical necessity of each family psychotherapy session and include the following: ?The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning; and?The summary of themes addressed in the family psychotherapy session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and?The degree of patient participation and interaction with the family members and leader, the reaction of the patient to the group, the group's reaction to the patient and the changes or lack of changes in patient symptoms and/or behavior as a result of the family psychotherapy session.It is the provider’s responsibility not to submit privileged information. This information should be kept apart from the clinical note in a separate section of the patient’s medical record. The following are some examples of privileged information:Information or facts of intimate personal contentTopics of themes discussed in therapy sessionsThe annotations taken during the psychotherapy sessionDetails of fantasies and dreamsSensitive information about other individuals in the patient’s life, etc.The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and 45 CFR§164.501 establish that the psychotherapy notes that are separated from the rest of the individual’s medical record do not include the following information, which should be part of the clinical note of the psychotherapy service:Medication prescription and monitoring,Counseling session start and stop times,The modalities and frequencies of treatment furnished,Results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.Psychotherapy notes are defined in 45 CFR§164.501 as “notes recorded by a mental health professional which document or analyze the contents of a counseling session and that are separated from the rest of a medical record.” The definition of psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of administered treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms prognosis, ongoing progress and progress to date. This class of information does not qualify as psychotherapy note material. Physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes.Under no circumstances shall the MACs, CERT, Recovery Auditors or ZPICs request that a provider submit psychotherapy notes defined in 45 CFR §164.501. The refusal of a provider to submit such information shall not result in the automatic denial of a claim.If the medical documentation includes any of the information included in the definition of psychotherapy notes in §164.501, as stated above, the provider is responsible for extracting information required to support that the claim is for reasonable and necessary services. MACs, Recovery Auditors, CERT or ZPICs shall review the claim using the supporting documentation submitted by the provider. If the provider does not submit information sufficient to demonstrate that services were medically necessary, the claim shall be denied.Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Individual patient requirements may differ; however, clear and concise documentation supporting medical necessity should be available upon request. Patient progress may be small or not be measurable at each visit. However, a trend should be measurable presenting signs of progression or regression in changes relating to behavior, thought processes, or medication management. When services are performed in excess of established parameters, they may be subject to review for medical necessity.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 disorder. When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated and there is no reasonable expectation of improvement, the psychological services are no longer considered reasonable or medically necessary. The documentation must support that the patient’s mental stability cannot be maintained without further psychotherapy treatment. The duration of a course of psychotherapy must be individualized for each patient.Psychiatric and/or psychological services routinely performed to evaluate and/or treat an adjustment disorder associated with placement in a nursing home do not constitute medical necessity. It is not expected that every patient upon entry to a nursing home receives a psychiatric diagnostic evaluation and/or psychotherapy services. The routine use of these services is considered screening and is not medically reasonable and necessary for Medicare coverage. However, some individuals enter a nursing home at a time of physical and cognitive decline and may require these services to arrive at a diagnosis, plan of care, and/or treatment. Decisions to perform these services to individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis, and the medical record documentation must clearly support the medical necessity for the performance of these services.The medical record documentation for psychotherapy must be clear and concise. Statements such as "supportive psychotherapy given" are not adequate. A clear and detailed description of what the psychotherapy entailed and how it is addressing the presenting problem of the patient should be evident.The patient must have the capacity to actively participate in all therapies prescribed, except for family therapy without the patient present (code 90846).Psychotherapy services are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art play), or social interaction. Therefore, procedure codes 90832-90838 should not be used to bill for these services.Physicians/NPP’s with a high utilization of these services per patient compared to their peers may be subject to review for medical necessity.Sources of Information and Basis for DecisionFCSO Reference LCD number - L33128American Psychiatric Association. Current Procedural Terminology (CPT) Code Changes for 2013. Accessed at: Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Nov. 2003.American Psychological Association. (May-June 2004). American Psychologist. Guidelines for Psychological Practice with Older Adults. Accessed at: Psychoanalytic Association, Psychoanalytic Psychotherapy. Accessed at: (January 2013).CPT Changes 2013: An Insider’s View, pages 232-244.CPT 2013, Professional Edition, pages 483-487.CPT 2014, Professional Edition, pages 527-530.Evidence-Based Caregiver Interventions in Geriatric Psychiatry. Richard Schultz PhD, et al. Psychiatric Clinics of North America. December 2005: 28, 1007-1038. Accessed at: for Managing Alzheimer’s Disease: Parts 1 and 2. Assessment. Jeffrey Cummings, et al. American Family Physician, 2002, Accessed at: and Level II 2013 Book, Professional EditionKaplan, H.I., Sadock, B.J., Grebb, J.A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry (9th ed.). Baltimore: Williams & Wilkins.LCDs and policies from other Medicare contractorsRevision History InformationRevision NumberEffective DateExplanationLast UpdatedR601/01/2017Revision Number: 3 Publication: December 2016 Connection LCR A/B2017-001Explanation of Revision: Annual 2017 HCPCS Update. Descriptors revised for CPT codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, and 90847. Additionally, this LCD was revised in the “Indications and Limitations of Coverage and/or Medical Necessity” and “Documentation Guidelines” sections to reflect descriptor changes for the following CPT/HCPCS codes: 90832-90838. The effective date of this revision is based on date of service.12/14/2016R510/01/2016Revision Number: 2Publication: October 2016 ConnectionLCR A/B2016-097Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Revised ICD-10-CM diagnosis code range F32.0-F32.8 to read F32.0-F32.89, F34.0-F34.8 to read F34.0-F34.89, F42-F43.8 to read F42.2-F43.8, and F50.00-F50.8 to read F50.00-F50.89. Deleted diagnosis codes F32.8, F34.8, F42.2, and F50.8. The effective date of this revision is based on date of service.10/10/2016R406/28/2016Revision Number: 1Publication: N/ALCR A/B2016-074Explanation of Revision: This LCD was revised based on a recommendation from the provider community to add ICD-10-CM diagnosis code Z01.818 to the “ICD-10 Codes that Support Medical Necessity” sections of the LCD. The effective date of this revision is for claims processed on or after 6/28/2016.06/24/2016R310/01/201508/11/2015 - - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.08/11/2015R210/01/20153/13/2015: The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.03/13/2015R110/01/201505/29/2014 – The language and/or ICD-10-CM diagnoses were updated to be consistent with current LCD language and ICD-9-CM coding.05/23/2014Associated DocumentsAttachmentsAttachments such as Coding Guidelines and Comment Summaries are available in the Medicare coverage database located on the Centers for Medicare & Medicaid Services (CMS) website. To view attachments, go to and enter the LCD ID in the search window; when the LCD is displayed select LCD Attachments from the "Jump to Section" dropdown list.Related Local Coverage DocumentsThis LCD has no Related Documents.Related National Coverage DocumentsThis LCD has no Related National Coverage Documents.KeywordsKeywordsN/A[back to top] ................
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