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Local Coverage Determination (LCD) for Group Psychotherapy (L28850)

 

 

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 L28850

 

 

LCD Title

Group Psychotherapy

 

 

Contractor's Determination Number A90853

 

Primary Geographic Jurisdiction opens in new window Florida

 

 

Oversight Region Region IV

 

 

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 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.

 

 

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 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

CMS Transmittal 98, Change Request 3457

Program Memorandum AB-01-135 (Change Request 1793), dated 09/25/2001

 

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 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).

 

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. 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.

 

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

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

085x 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 - 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 XX000 Not Applicable

 

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 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:

 

• 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 group 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 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. 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, 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. 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:

 

• 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

 

• Start and stop 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

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/

 

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]

 

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 (L28850) replaces LCD L13800 as the policy in notice. This document (L28850) 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 75 was changed 8/1/2010 - The description for Bill Type Code 76 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

 

8/1/2010 - The description for Revenue code 0900 was changed 8/1/2010 - The description for Revenue code 0915 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

 

Related Documents

This LCD has no Related Documents.

 

LCD Attachments

There are no attachments for this LCD.

 

All Versions

Updated on 09/14/2011 with effective dates 10/01/2011 - N/A Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 11/29/2008 with effective dates 02/16/2009 - N/A Read the LCD Disclaimer opens in new window

 

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