L28839-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Family Psychotherapy (L28839)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28839

LCD Title

Family Psychotherapy

Contractor's Determination Number A90847

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (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 Transmittal 98, Change Request 3457

CMS Manual System, Pub. 100-01, Medicare General Information, Chapter 3, Section 30-30.3

CMS Manual System, Pub. 100-08, Medicare Program Integrity, Chapter 3, Section 3.4.1.2

Indications and Limitations of Coverage and/or Medical Necessity

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, psychological symptoms associated with loss, reverse or change maladaptive patterns of behavior and encourage personality growth and development. 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.

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. Group psychotherapy sessions for multiple families are utilized when similar dynamics are occurring due to the commonality of problems in the family members under treatment.

Medicare will consider family psychotherapy 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 Medicare B 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 related 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.

Coding Information

Bill Type Codes:

Contractors 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.

013x Hospital Outpatient 071x Clinic - Rural Health

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 076x Clinic - Community Mental Health Center

Revenue Codes:

Contractors 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.

0900 Behavioral Health Treatment/Services - General Classification 0916 Behavioral Health Treatment/Services - Family Therapy

CPT/HCPCS Codes

90846 FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT)

90847 FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT PRESENT)

ICD-9 Codes that Support Medical Necessity

290.0 - 299.91 opens in new window

300.00 - 316 opens in new window

SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE

ANXIETY STATE UNSPECIFIED - PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE

317 MILD INTELLECTUAL DISABILITIES

318.0 - 318.2 opens in new window

MODERATE INTELLECTUAL DISABILITIES - PROFOUND INTELLECTUAL DISABILITIES

331.0 ALZHEIMER'S DISEASE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

On a periodic basis, the patient’s capacity to participate and benefit from psychotherapy should be documented. Such documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, the 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 should reflect adjustments in the treatment plan and reveal the dynamics of treatment in the family therapy setting.

It is expected that the treatment plan for a patient receiving outpatient psychotherapy services, (i.e., measurable 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.

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.

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 problems.

Psychotherapy notes are defined in 45 CFR §164.501as “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 expressly excludes 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 diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date etc., and 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 a contractor request a provider to submit notes defined in 45 CFR §164.501. The refusal of a provider to submit such information shall not result in the denial of a claim.

If the medical record includes any of the information excluded from the definition of psychotherapy notes in

§164.501, as stated above, the provider is responsible for extracting the information required to support that the claim is reasonable and necessary. Contractors must review the claim using all supporting documentation submitted by the provider. If the provider does not submit sufficient information to demonstrate that services were medically necessary, the claim will be denied.

When contractors cannot make a coverage or coding determination based upon the information on the claim and its attachments, the contractors may solicit additional documentation from the provider by issuing an additional documentation request (ADR). Contractors must request records related to the claim(s) being reviewed.

For a patient with profound intellectual disabilities(ICD-9-CM 318.2) additional documentation must be maintained in the medical record that demonstrates the patient’s ability to effectively communicate with the therapist, family members and interact with sufficient quality while working to improve or alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and be taught coping mechanisms for loss acceptance if indicated.

At various times providers will continue to receive documentation requests from Medicare. When documentation is requested, the provider will be required to respond by submitting medical record information. The provider has the option to:

• Submit original psychotherapy notes. This requires the patient to authorize release of the record.

• In responding to these requests the provider can extract information from the psychotherapy note and submit documentation in the form of a summary. This summary must include documentation outlining the patient’s need for the services provided (i.e., that the services provided were reasonable and medically necessary).

The summary document must include all of the following information to support the medical necessity of the psychotherapy session:

• Description of emotional or behavioral symptoms that demonstrate inappropriate or maladaptive functioning that is a significant change in the patient’s baseline level of functioning

• Progress towards measurable treatment goals since last session

• Face to face time of the psychotherapy encounter/session

• Description of treatment, including therapeutic interventions such as behavior modification, supportive interaction, and discussion of reality provided to the patient during the psychotherapy session

• Degree of patient participation in the psychotherapy session

• Patient reaction to the psychotherapy session

If the provider does not submit information when requested, that clearly demonstrates that the service rendered was reasonable and medically necessary, the claim will be denied.

Appendices

Utilization Guidelines It 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.

Sources of Information and Basis for Decision

American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Arlington (VA): American Psychiatric Association; 2003 Nov. 117p.

American Psychological Association. (2003). Guidelines for Psychological Practice with Older Adults. [On-line] http://www.apa.org/practice/Guidelines_for_Psychological_Practice_with_Older_Adults.pdf

Guidelines for Managing Alzheimer’s Disease: Part 1. Assessment. Jeffrey Cummings, et al. American Family Physician, 2002, 65 (11).

Evidence-Based Caregiver Interventions in Geriatric Psychiatry. Richard Schultz PhD, et al. Psychiatric Clinics of North America. December 2005. 28 (4).

Kaplan, H.I., Sadock, B.J., Grebb, J.A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry (9th ed.). Baltimore: Williams & Wilkins.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation

with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number: 1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Descriptor change for ICD-9-CM codes 317 and 318.0-

318.2. Changed language in the “Documentation requirements” section of the LCD for ICD-9-CM code 318.2. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28839) replaces LCD L1196 as the policy in notice. This document (L28839) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 76 was changed

8/1/2010 - The description for Revenue code 0900 was changed 8/1/2010 - The description for Revenue code 0916 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change