LCD/NCD Portal
Automated World Health
L28850
GROUP PSYCHOTHERAPY
10/01/2011
Indications and Limitations of Coverage and/or Medical Necessity
• Medicare will consider group therapy (90853) to be 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.
o The issues presented and explored in the group setting should evolve towards a theme or a therapeutic goal.
o 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.
o This treatment plan must be adhered to, and should be endorsed and monitored by the treating physician or physician of record.
o 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.
o 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.
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.
13x Hospital Outpatient
75x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
76x Clinic - Community Mental Health Center
85x Critical Access Hospital
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
0915 Behavioral Health Treatment/Services - Group Therapy
CPT/HCPCS Codes
90853 GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP)
ICD-9 Codes that Support Medical Necessity
290.0 SENILE DEMENTIA UNCOMPLICATED
290.10 PRESENILE DEMENTIA UNCOMPLICATED
290.11 PRESENILE DEMENTIA WITH DELIRIUM
290.12 PRESENILE DEMENTIA WITH DELUSIONAL FEATURES
290.13 PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES
290.20 SENILE DEMENTIA WITH DELUSIONAL FEATURES
290.21 SENILE DEMENTIA WITH DEPRESSIVE FEATURES
290.3 SENILE DEMENTIA WITH DELIRIUM
290.40 VASCULAR DEMENTIA, UNCOMPLICATED
290.41 VASCULAR DEMENTIA, WITH DELIRIUM
290.42 VASCULAR DEMENTIA, WITH DELUSIONS
290.43 VASCULAR DEMENTIA, WITH DEPRESSED MOOD
290.8 OTHER SPECIFIED SENILE PSYCHOTIC CONDITIONS
290.9 UNSPECIFIED SENILE PSYCHOTIC CONDITION
291.0 ALCOHOL WITHDRAWAL DELIRIUM
291.1 ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER
291.2 ALCOHOL-INDUCED PERSISTING DEMENTIA
291.3 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS
291.4 IDIOSYNCRATIC ALCOHOL INTOXICATION
291.5 ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS
291.81 ALCOHOL WITHDRAWAL
291.82 ALCOHOL INDUCED SLEEP DISORDERS
291.89 OTHER SPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS
291.9 UNSPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS
292.0 DRUG WITHDRAWAL
292.11 DRUG-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS
292.12 DRUG-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS
292.2 PATHOLOGICAL DRUG INTOXICATION
292.81 DRUG-INDUCED DELIRIUM
292.82 DRUG-INDUCED PERSISTING DEMENTIA
292.83 DRUG-INDUCED PERSISTING AMNESTIC DISORDER
292.84 DRUG-INDUCED MOOD DISORDER
292.85 DRUG INDUCED SLEEP DISORDERS
292.89 OTHER SPECIFIED DRUG-INDUCED MENTAL DISORDERS
292.9 UNSPECIFIED DRUG-INDUCED MENTAL DISORDER
293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE
293.1 SUBACUTE DELIRIUM
293.81 PSYCHOTIC DISORDER WITH DELUSIONS IN CONDITIONS CLASSIFIED ELSEWHERE
293.82 PSYCHOTIC DISORDER WITH HALLUCINATIONS IN CONDITIONS CLASSIFIED ELSEWHERE
293.83 MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
293.84 ANXIETY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
293.89 OTHER SPECIFIED TRANSIENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE, OTHER
293.9 UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
294.0 AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
294.10 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE
294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE
294.20 DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE
294.8 OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
294.9 UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
295.00 SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.01 SIMPLE TYPE SCHIZOPHRENIA SUBCHRONIC STATE
295.02 SIMPLE TYPE SCHIZOPHRENIA CHRONIC STATE
295.03 SIMPLE TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.04 SIMPLE TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.05 SIMPLE TYPE SCHIZOPHRENIA IN REMISSION
295.10 DISORGANIZED TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.11 DISORGANIZED TYPE SCHIZOPHRENIA SUBCHRONIC STATE
295.12 DISORGANIZED TYPE SCHIZOPHRENIA CHRONIC STATE
295.13 DISORGANIZED TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.14 DISORGANIZED TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.15 DISORGANIZED TYPE SCHIZOPHRENIA IN REMISSION
295.20 CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.21 CATATONIC TYPE SCHIZOPHRENIA SUBCHRONIC STATE
295.22 CATATONIC TYPE SCHIZOPHRENIA CHRONIC STATE
295.23 CATATONIC TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.24 CATATONIC TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.25 CATATONIC TYPE SCHIZOPHRENIA IN REMISSION
295.30 PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.31 PARANOID TYPE SCHIZOPHRENIA SUBCHRONIC STATE
295.32 PARANOID TYPE SCHIZOPHRENIA CHRONIC STATE
295.33 PARANOID TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.34 PARANOID TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.35 PARANOID TYPE SCHIZOPHRENIA IN REMISSION
295.40 SCHIZOPHRENIFORM DISORDER, UNSPECIFIED
295.41 SCHIZOPHRENIFORM DISORDER, SUBCHRONIC
295.42 SCHIZOPHRENIFORM DISORDER, CHRONIC
295.43 SCHIZOPHRENIFORM DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION
295.44 SCHIZOPHRENIFORM DISORDER, CHRONIC WITH ACUTE EXACERBATION
295.45 SCHIZOPHRENIFORM DISORDER, IN REMISSION
295.50 LATENT SCHIZOPHRENIA UNSPECIFIED STATE
295.51 LATENT SCHIZOPHRENIA SUBCHRONIC STATE
295.52 LATENT SCHIZOPHRENIA CHRONIC STATE
295.53 LATENT SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.54 LATENT SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.55 LATENT SCHIZOPHRENIA IN REMISSION
295.60 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, UNSPECIFIED
295.61 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC
295.62 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC
295.63 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC WITH ACUTE EXACERBATION
295.64 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC WITH ACUTE EXACERBATION
295.65 SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, IN REMISSION
295.70 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED
295.71 SCHIZOAFFECTIVE DISORDER, SUBCHRONIC
295.72 SCHIZOAFFECTIVE DISORDER, CHRONIC
295.73 SCHIZOAFFECTIVE DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION
295.74 SCHIZOAFFECTIVE DISORDER, CHRONIC WITH ACUTE EXACERBATION
295.75 SCHIZOAFFECTIVE DISORDER, IN REMISSION
295.80 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA UNSPECIFIED STATE
295.81 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA SUBCHRONIC STATE
295.82 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA CHRONIC STATE
295.83 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.84 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.85 OTHER SPECIFIED TYPES OF SCHIZOPHRENIA IN REMISSION
295.90 UNSPECIFIED TYPE SCHIZOPHRENIA UNSPECIFIED STATE
295.91 UNSPECIFIED TYPE SCHIZOPHRENIA SUBCHRONIC STATE
295.92 UNSPECIFIED TYPE SCHIZOPHRENIA CHRONIC STATE
295.93 UNSPECIFIED TYPE SCHIZOPHRENIA SUBCHRONIC STATE WITH ACUTE EXACERBATION
295.94 UNSPECIFIED TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION
295.95 UNSPECIFIED TYPE SCHIZOPHRENIA IN REMISSION
296.00 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED
296.01 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD
296.02 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE
296.03 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.04 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.05 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION
296.06 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION
296.10 MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE
296.11 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE
296.12 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE
296.13 MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.14 MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.15 MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.16 MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION
296.20 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE
296.21 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MILD DEGREE
296.22 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE DEGREE
296.23 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.24 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.25 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.26 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN FULL REMISSION
296.30 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE
296.31 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE
296.32 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE
296.33 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.34 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.35 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.36 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION
296.40 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, UNSPECIFIED
296.41 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD
296.42 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MODERATE
296.43 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.44 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.45 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN PARTIAL OR UNSPECIFIED REMISSION
296.46 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN FULL REMISSION
296.50 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED
296.51 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD
296.52 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE
296.53 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.54 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.55 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR UNSPECIFIED REMISSION
296.56 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION
296.60 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED
296.61 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD
296.62 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE
296.63 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
296.64 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
296.65 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION
296.66 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION
296.7 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED
296.80 BIPOLAR DISORDER, UNSPECIFIED
296.81 ATYPICAL MANIC DISORDER
296.82 ATYPICAL DEPRESSIVE DISORDER
296.89 OTHER AND UNSPECIFIED BIPOLAR DISORDERS, OTHER
296.90 UNSPECIFIED EPISODIC MOOD DISORDER
296.99 OTHER SPECIFIED EPISODIC MOOD DISORDER
297.0 PARANOID STATE SIMPLE
297.1 DELUSIONAL DISORDER
297.2 PARAPHRENIA
297.3 SHARED PSYCHOTIC DISORDER
297.8 OTHER SPECIFIED PARANOID STATES
297.9 UNSPECIFIED PARANOID STATE
298.0 DEPRESSIVE TYPE PSYCHOSIS
298.1 EXCITATIVE TYPE PSYCHOSIS
298.2 REACTIVE CONFUSION
298.3 ACUTE PARANOID REACTION
298.4 PSYCHOGENIC PARANOID PSYCHOSIS
298.8 OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS
298.9 UNSPECIFIED PSYCHOSIS
299.00 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
299.01 AUTISTIC DISORDER, RESIDUAL STATE
299.10 CHILDHOOD DISINTEGRATIVE DISORDER, CURRENT OR ACTIVE STATE
299.11 CHILDHOOD DISINTEGRATIVE DISORDER, RESIDUAL STATE
299.80 OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, CURRENT OR ACTIVE STATE
299.81 OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, RESIDUAL STATE
299.90 UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, CURRENT OR ACTIVE STATE
299.91 UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE
300.00 ANXIETY STATE UNSPECIFIED
300.01 PANIC DISORDER WITHOUT AGORAPHOBIA
300.02 GENERALIZED ANXIETY DISORDER
300.09 OTHER ANXIETY STATES
300.10 HYSTERIA UNSPECIFIED
300.11 CONVERSION DISORDER
300.12 DISSOCIATIVE AMNESIA
300.13 DISSOCIATIVE FUGUE
300.14 DISSOCIATIVE IDENTITY DISORDER
300.15 DISSOCIATIVE DISORDER OR REACTION UNSPECIFIED
300.16 FACTITIOUS DISORDER WITH PREDOMINANTLY PSYCHOLOGICAL SIGNS AND SYMPTOMS
300.19 OTHER AND UNSPECIFIED FACTITIOUS ILLNESS
300.20 PHOBIA UNSPECIFIED
300.21 AGORAPHOBIA WITH PANIC DISORDER
300.22 AGORAPHOBIA WITHOUT PANIC ATTACKS
300.23 SOCIAL PHOBIA
300.29 OTHER ISOLATED OR SPECIFIC PHOBIAS
300.3 OBSESSIVE-COMPULSIVE DISORDERS
300.4 DYSTHYMIC DISORDER
300.5 NEURASTHENIA
300.6 DEPERSONALIZATION DISORDER
300.7 HYPOCHONDRIASIS
300.81 SOMATIZATION DISORDER
300.82 UNDIFFERENTIATED SOMATOFORM DISORDER
300.89 OTHER SOMATOFORM DISORDERS
300.9 UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER
301.0 PARANOID PERSONALITY DISORDER
301.10 AFFECTIVE PERSONALITY DISORDER UNSPECIFIED
301.11 CHRONIC HYPOMANIC PERSONALITY DISORDER
301.12 CHRONIC DEPRESSIVE PERSONALITY DISORDER
301.13 CYCLOTHYMIC DISORDER
301.20 SCHIZOID PERSONALITY DISORDER UNSPECIFIED
301.21 INTROVERTED PERSONALITY
301.22 SCHIZOTYPAL PERSONALITY DISORDER
301.3 EXPLOSIVE PERSONALITY DISORDER
301.4 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
301.50 HISTRIONIC PERSONALITY DISORDER UNSPECIFIED
301.51 CHRONIC FACTITIOUS ILLNESS WITH PHYSICAL SYMPTOMS
301.59 OTHER HISTRIONIC PERSONALITY DISORDER
301.6 DEPENDENT PERSONALITY DISORDER
301.7 ANTISOCIAL PERSONALITY DISORDER
301.81 NARCISSISTIC PERSONALITY DISORDER
301.82 AVOIDANT PERSONALITY DISORDER
301.83 BORDERLINE PERSONALITY DISORDER
301.84 PASSIVE-AGGRESSIVE PERSONALITY
301.89 OTHER PERSONALITY DISORDERS
301.9 UNSPECIFIED PERSONALITY DISORDER
302.0 EGO-DYSTONIC SEXUAL ORIENTATION
302.1 ZOOPHILIA
302.2 PEDOPHILIA
302.3 TRANSVESTIC FETISHISM
302.4 EXHIBITIONISM
302.50 TRANS-SEXUALISM WITH UNSPECIFIED SEXUAL HISTORY
302.51 TRANS-SEXUALISM WITH ASEXUAL HISTORY
302.52 TRANS-SEXUALISM WITH HOMOSEXUAL HISTORY
302.53 TRANS-SEXUALISM WITH HETEROSEXUAL HISTORY
302.6 GENDER IDENTITY DISORDER IN CHILDREN
302.70 PSYCHOSEXUAL DYSFUNCTION UNSPECIFIED
302.71 HYPOACTIVE SEXUAL DESIRE DISORDER
302.72 PSYCHOSEXUAL DYSFUNCTION WITH INHIBITED SEXUAL EXCITEMENT
302.73 FEMALE ORGASMIC DISORDER
302.74 MALE ORGASMIC DISORDER
302.75 PREMATURE EJACULATION
302.76 DYSPAREUNIA, PSYCHOGENIC
302.79 PSYCHOSEXUAL DYSFUNCTION WITH OTHER SPECIFIED PSYCHOSEXUAL DYSFUNCTIONS
302.81 FETISHISM
302.82 VOYEURISM
302.83 SEXUAL MASOCHISM
302.84 SEXUAL SADISM
302.85 GENDER IDENTITY DISORDER IN ADOLESCENTS OR ADULTS
302.89 OTHER SPECIFIED PSYCHOSEXUAL DISORDERS
302.9 UNSPECIFIED PSYCHOSEXUAL DISORDER
303.00 ACUTE ALCOHOLIC INTOXICATION IN ALCOHOLISM UNSPECIFIED DRINKING BEHAVIOR
303.01 ACUTE ALCOHOLIC INTOXICATION IN ALCOHOLISM CONTINUOUS DRINKING BEHAVIOR
303.02 ACUTE ALCOHOLIC INTOXICATION IN ALCOHOLISM EPISODIC DRINKING BEHAVIOR
303.03 ACUTE ALCOHOLIC INTOXICATION IN ALCOHOLISM IN REMISSION
303.90 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED DRINKING BEHAVIOR
303.91 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE CONTINUOUS DRINKING BEHAVIOR
303.92 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE EPISODIC DRINKING BEHAVIOR
303.93 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION
304.00 OPIOID TYPE DEPENDENCE UNSPECIFIED USE
304.01 OPIOID TYPE DEPENDENCE CONTINUOUS USE
304.02 OPIOID TYPE DEPENDENCE EPISODIC USE
304.03 OPIOID TYPE DEPENDENCE IN REMISSION
304.10 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, UNSPECIFIED
304.11 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS
304.12 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC
304.13 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION
304.20 COCAINE DEPENDENCE UNSPECIFIED USE
304.21 COCAINE DEPENDENCE CONTINUOUS USE
304.22 COCAINE DEPENDENCE EPISODIC USE
304.23 COCAINE DEPENDENCE IN REMISSION
304.30 CANNABIS DEPENDENCE UNSPECIFIED USE
304.31 CANNABIS DEPENDENCE CONTINUOUS USE
304.32 CANNABIS DEPENDENCE EPISODIC USE
304.33 CANNABIS DEPENDENCE IN REMISSION
304.40 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE UNSPECIFIED USE
304.41 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE CONTINUOUS USE
304.42 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE EPISODIC USE
304.43 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE IN REMISSION
304.50 HALLUCINOGEN DEPENDENCE UNSPECIFIED USE
304.51 HALLUCINOGEN DEPENDENCE CONTINUOUS USE
304.52 HALLUCINOGEN DEPENDENCE EPISODIC USE
304.53 HALLUCINOGEN DEPENDENCE IN REMISSION
304.60 OTHER SPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
304.61 OTHER SPECIFIED DRUG DEPENDENCE CONTINUOUS USE
304.62 OTHER SPECIFIED DRUG DEPENDENCE EPISODIC USE
304.63 OTHER SPECIFIED DRUG DEPENDENCE IN REMISSION
304.70 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE UNSPECIFIED USE
304.71 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE CONTINUOUS USE
304.72 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE EPISODIC USE
304.73 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE IN REMISSION
304.80 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG UNSPECIFIED USE
304.81 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG CONTINUOUS USE
304.82 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG EPISODIC USE
304.83 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG IN REMISSION
304.90 UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
304.91 UNSPECIFIED DRUG DEPENDENCE CONTINUOUS USE
304.92 UNSPECIFIED DRUG DEPENDENCE EPISODIC USE
304.93 UNSPECIFIED DRUG DEPENDENCE IN REMISSION
305.00 NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR
305.01 NONDEPENDENT ALCOHOL ABUSE CONTINUOUS DRINKING BEHAVIOR
305.02 NONDEPENDENT ALCOHOL ABUSE EPISODIC DRINKING BEHAVIOR
305.03 NONDEPENDENT ALCOHOL ABUSE IN REMISSION
305.1 NONDEPENDENT TOBACCO USE DISORDER
305.20 NONDEPENDENT CANNABIS ABUSE UNSPECIFIED USE
305.21 NONDEPENDENT CANNABIS ABUSE CONTINUOUS USE
305.22 NONDEPENDENT CANNABIS ABUSE EPISODIC USE
305.23 NONDEPENDENT CANNABIS ABUSE IN REMISSION
305.30 NONDEPENDENT HALLUCINOGEN ABUSE UNSPECIFIED USE
305.31 NONDEPENDENT HALLUCINOGEN ABUSE CONTINUOUS USE
305.32 NONDEPENDENT HALLUCINOGEN ABUSE EPISODIC USE
305.33 NONDEPENDENT HALLUCINOGEN ABUSE IN REMISSION
305.40 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED
305.41 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, CONTINUOUS
305.42 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, EPISODIC
305.43 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION
305.50 NONDEPENDENT OPIOID ABUSE UNSPECIFIED USE
305.51 NONDEPENDENT OPIOID ABUSE CONTINUOUS USE
305.52 NONDEPENDENT OPIOID ABUSE EPISODIC USE
305.53 NONDEPENDENT OPIOID ABUSE IN REMISSION
305.60 NONDEPENDENT COCAINE ABUSE UNSPECIFIED USE
305.61 NONDEPENDENT COCAINE ABUSE CONTINUOUS USE
305.62 NONDEPENDENT COCAINE ABUSE EPISODIC USE
305.63 NONDEPENDENT COCAINE ABUSE IN REMISSION
305.70 NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE UNSPECIFIED USE
305.71 NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE CONTINUOUS USE
305.72 NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE EPISODIC USE
305.73 NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE IN REMISSION
305.80 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE UNSPECIFIED USE
305.81 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE CONTINUOUS USE
305.82 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE EPISODIC USE
305.83 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE IN REMISSION
305.90 OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED USE
305.91 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE CONTINUOUS USE
305.92 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE EPISODIC USE
305.93 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE IN REMISSION
306.0 MUSCULOSKELETAL MALFUNCTION ARISING FROM MENTAL FACTORS
306.1 RESPIRATORY MALFUNCTION ARISING FROM MENTAL FACTORS
306.2 CARDIOVASCULAR MALFUNCTION ARISING FROM MENTAL FACTORS
306.3 SKIN DISORDER ARISING FROM MENTAL FACTORS
306.4 GASTROINTESTINAL MALFUNCTION ARISING FROM MENTAL FACTORS
306.50 PSYCHOGENIC GENITOURINARY MALFUNCTION UNSPECIFIED
306.51 PSYCHOGENIC VAGINISMUS
306.52 PSYCHOGENIC DYSMENORRHEA
306.53 PSYCHOGENIC DYSURIA
306.59 OTHER GENITOURINARY MALFUNCTION ARISING FROM MENTAL FACTORS
306.6 ENDOCRINE DISORDER ARISING FROM MENTAL FACTORS
306.7 DISORDER OF ORGANS OF SPECIAL SENSE ARISING FROM MENTAL FACTORS
306.8 OTHER SPECIFIED PSYCHOPHYSIOLOGICAL MALFUNCTION
306.9 UNSPECIFIED PSYCHOPHYSIOLOGICAL MALFUNCTION
307.0 ADULT ONSET FLUENCY DISORDER
307.1 ANOREXIA NERVOSA
307.20 TIC DISORDER UNSPECIFIED
307.21 TRANSIENT TIC DISORDER
307.22 CHRONIC MOTOR OR VOCAL TIC DISORDER
307.23 TOURETTE’S DISORDER
307.3 STEREOTYPIC MOVEMENT DISORDER
307.40 NONORGANIC SLEEP DISORDER UNSPECIFIED
307.41 TRANSIENT DISORDER OF INITIATING OR MAINTAINING SLEEP
307.42 PERSISTENT DISORDER OF INITIATING OR MAINTAINING SLEEP
307.43 TRANSIENT DISORDER OF INITIATING OR MAINTAINING WAKEFULNESS
307.44 PERSISTENT DISORDER OF INITIATING OR MAINTAINING WAKEFULNESS
307.45 CIRCADIAN RHYTHM SLEEP DISORDER OF NONORGANIC ORIGIN
307.46 SLEEP AROUSAL DISORDER
307.47 OTHER DYSFUNCTIONS OF SLEEP STAGES OR AROUSAL FROM SLEEP
307.48 REPETITIVE INTRUSIONS OF SLEEP
307.49 OTHER SPECIFIC DISORDERS OF SLEEP OF NONORGANIC ORIGIN
307.50 EATING DISORDER UNSPECIFIED
307.51 BULIMIA NERVOSA
307.52 PICA
307.53 RUMINATION DISORDER
307.54 PSYCHOGENIC VOMITING
307.59 OTHER DISORDERS OF EATING
307.6 ENURESIS
307.7 ENCOPRESIS
307.80 PSYCHOGENIC PAIN SITE UNSPECIFIED
307.81 TENSION HEADACHE
307.89 OTHER, PAIN DISORDER RELATED TO PSYCHOLOGICAL FACTORS
307.9 OTHER AND UNSPECIFIED SPECIAL SYMPTOMS OR SYNDROMES NOT ELSEWHERE CLASSIFIED
308.0 PREDOMINANT DISTURBANCE OF EMOTIONS
308.1 PREDOMINANT DISTURBANCE OF CONSCIOUSNESS
308.2 PREDOMINANT PSYCHOMOTOR DISTURBANCE
308.3 OTHER ACUTE REACTIONS TO STRESS
308.4 MIXED DISORDERS AS REACTION TO STRESS
308.9 UNSPECIFIED ACUTE REACTION TO STRESS
309.0 ADJUSTMENT DISORDER WITH DEPRESSED MOOD
309.1 ADJUSTMENT REACTION WITH PROLONGED DEPRESSIVE REACTION
309.21 SEPARATION ANXIETY DISORDER
309.22 EMANCIPATION DISORDER OF ADOLESCENCE AND EARLY ADULT LIFE
309.23 SPECIFIC ACADEMIC OR WORK INHIBITION
309.24 ADJUSTMENT DISORDER WITH ANXIETY
309.28 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD
309.29 OTHER ADJUSTMENT REACTIONS WITH PREDOMINANT DISTURBANCE OF OTHER EMOTIONS
309.3 ADJUSTMENT DISORDER WITH DISTURBANCE OF CONDUCT
309.4 ADJUSTMENT DISORDER WITH MIXED DISBURBANCE OF EMOTIONS AND CONDUCT
309.81 POSTTRAUMATIC STRESS DISORDER
309.82 ADJUSTMENT REACTION WITH PHYSICAL SYMPTOMS
309.83 ADJUSTMENT REACTION WITH WITHDRAWAL
309.89 OTHER SPECIFIED ADJUSTMENT REACTIONS
309.9 UNSPECIFIED ADJUSTMENT REACTION
310.0 FRONTAL LOBE SYNDROME
310.1 PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE
310.2 POSTCONCUSSION SYNDROME
310.81 PSEUDOBULBAR AFFECT
310.89 OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE
310.9 UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE
311 DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED
312.00 UNDERSOCIALIZED CONDUCT DISORDER AGGRESSIVE TYPE UNSPECIFIED DEGREE
312.01 UNDERSOCIALIZED CONDUCT DISORDER AGGRESSIVE TYPE MILD DEGREE
312.02 UNDERSOCIALIZED CONDUCT DISORDER AGGRESSIVE TYPE MODERATE DEGREE
312.03 UNDERSOCIALIZED CONDUCT DISORDER AGGRESSIVE TYPE SEVERE DEGREE
312.10 UNDERSOCIALIZED CONDUCT DISORDER UNAGGRESSIVE TYPE UNSPECIFIED DEGREE
312.11 UNDERSOCIALIZED CONDUCT DISORDER UNAGGRESSIVE TYPE MILD DEGREE
312.12 UNDERSOCIALIZED CONDUCT DISORDER UNAGGRESSIVE TYPE MODERATE DEGREE
312.13 UNDERSOCIALIZED CONDUCT DISORDER UNAGGRESSIVE TYPE SEVERE DEGREE
312.20 SOCIALIZED CONDUCT DISORDER UNSPECIFIED DEGREE
312.21 SOCIALIZED CONDUCT DISORDER MILD DEGREE
312.22 SOCIALIZED CONDUCT DISORDER MODERATE DEGREE
312.23 SOCIALIZED CONDUCT DISORDER SEVERE DEGREE
312.30 IMPULSE CONTROL DISORDER UNSPECIFIED
312.31 PATHOLOGICAL GAMBLING
312.32 KLEPTOMANIA
312.33 PYROMANIA
312.34 INTERMITTENT EXPLOSIVE DISORDER
312.35 ISOLATED EXPLOSIVE DISORDER
312.39 OTHER DISORDERS OF IMPULSE CONTROL
312.4 MIXED DISTURBANCE OF CONDUCT AND EMOTIONS
312.81 CONDUCT DISORDER CHILDHOOD ONSET TYPE
312.82 CONDUCT DISORDER ADOLESCENT ONSET TYPE
312.89 OTHER SPECIFIED CONDUCT DISORDER NOT ELSEWHERE CLASSIFIED
312.9 UNSPECIFIED DISTURBANCE OF CONDUCT
313.0 OVERANXIOUS DISORDER SPECIFIC TO CHILDHOOD AND ADOLESCENCE
313.1 MISERY AND UNHAPPINESS DISORDER SPECIFIC TO CHILDHOOD AND ADOLESCENCE
313.21 SHYNESS DISORDER OF CHILDHOOD
313.22 INTROVERTED DISORDER OF CHILDHOOD
313.23 SELECTIVE MUTISM
313.3 RELATIONSHIP PROBLEMS SPECIFIC TO CHILDHOOD AND ADOLESCENCE
313.81 OPPOSITIONAL DEFIANT DISORDER
313.82 IDENTITY DISORDER OF CHILDHOOD OR ADOLESCENCE
313.83 ACADEMIC UNDERACHIEVEMENT DISORDER OF CHILDHOOD OR ADOLESCENCE
313.89 OTHER EMOTIONAL DISTURBANCES OF CHILDHOOD OR ADOLESCENCE
313.9 UNSPECIFIED EMOTIONAL DISTURBANCE OF CHILDHOOD OR ADOLESCENCE
314.00 ATTENTION DEFICIT DISORDER OF CHILDHOOD WITHOUT HYPERACTIVITY
314.01 ATTENTION DEFICIT DISORDER OF CHILDHOOD WITH HYPERACTIVITY
314.1 HYPERKINESIS OF CHILDHOOD WITH DEVELOPMENTAL DELAY
314.2 HYPERKINETIC CONDUCT DISORDER OF CHILDHOOD
314.8 OTHER SPECIFIED MANIFESTATIONS OF HYPERKINETIC SYNDROME OF CHILDHOOD
314.9 UNSPECIFIED HYPERKINETIC SYNDROME OF CHILDHOOD
315.00 DEVELOPMENTAL READING DISORDER UNSPECIFIED
315.01 ALEXIA
315.02 DEVELOPMENTAL DYSLEXIA
315.09 OTHER SPECIFIC DEVELOPMENTAL READING DISORDER
315.1 MATHEMATICS DISORDER
315.2 OTHER SPECIFIC DEVELOPMENTAL LEARNING DIFFICULTIES
315.31 EXPRESSIVE LANGUAGE DISORDER
315.32 MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER
315.34 SPEECH AND LANGUAGE DEVELOPMENTAL DELAY DUE TO HEARING LOSS
315.35 CHILDHOOD ONSET FLUENCY DISORDER
315.39 OTHER DEVELOPMENTAL SPEECH DISORDER
315.4 DEVELOPMENTAL COORDINATION DISORDER
315.5 MIXED DEVELOPMENT DISORDER
315.8 OTHER SPECIFIED DELAYS IN DEVELOPMENT
315.9 UNSPECIFIED DELAY IN DEVELOPMENT
316 PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE
317 MILD INTELLECTUAL DISABILITIES
318.0 MODERATE INTELLECTUAL DISABILITIES
318.1 SEVERE INTELLECTUAL DISABILITIES
318.2 PROFOUND INTELLECTUAL DISABILITIES
331.0 ALZHEIMER'S DISEASE
Documentation Requirements
• On a periodic basis, the patient’s capacity to participate and benefit from psychotherapy should be documented.
o 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.
o For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient.
o For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected.
o Documentation should reflect adjustments in the treatment plan and reveal the dynamics of treatment in the group 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 group psychotherapy session and include the following:
o The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning.
And
o The summary of themes addressed in the group psychotherapy session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality.
And
o The degree of patient participation and interaction with the group 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 group psychotherapy session.
• The rationale for any departure from the plan or extension of therapy should be documented in the medical record.
o 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.”
o 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.
o 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.
o 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, group 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.
o 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.
OR
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:
o 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
o Progress towards measurable treatment goals since last session.
o Start and stop time of the psychotherapy encounter/session.
o Description of treatment, including therapeutic interventions such as behavior modification, supportive interaction, and discussion of reality provided to the patient during the psychotherapy session.
o Degree of patient participation in the psychotherapy session.
o 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.
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.
Treatment Logic
• Psychotherapy is the treatment of mental illness and behavior disturbances in which the provider establishes a professional contact 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 or accept losses, especially related to aging and coping with such.
• 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 practitioners or clinical nurse specialists.
• 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).
Sources of Information and Basis for Decision
Chaimowitz, M.B. (2003, January 25). Psychotherapy in Psychiatry. CPA Clinical Guidelines and Position Papers. Article retrieved August 12, 2005 from http://cpa-apc.org/
FCSO LCD 29185, Group Psychotherapy10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.
Ingenix. (2005). Coding and Payment Guide, Behavioral Health Services. (5th ed.). Ingenix Incorporated.
Other Carrier Local Coverage Determinations
American Psychiatric Association (2005). Treating Alzheimer’s Disease and other Dementias of Late Life. Retrieved August 30, 2005 [Online]
AMA CPT Copyright Statement
CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
© Automated Clinical Guidelines, LLC 2011-2014
CMS LCD L28850 Group Psychotherapy