L28893-LCD

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Local Coverage Determination (LCD) for Interactive Psychiatric Services (L28893)

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 L28893

LCD Title

Interactive Psychiatric Services

Contractor's Determination Number A90802

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 Manual System, Pub. 100-1, Medicare General Information, Chapter 3, Section 30-30.3

CMS Manual System, Bub. 100-4, Medicare Claims Processing, Chapter 12, Section 120B and 210.1

CMS Manual System, Pub. 100-8, 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

The interactive psychiatric techniques are utilized primarily to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. 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 is 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 codes should not be billed.

Note: The Indications and Limitations of Coverage and/or Medical Necessity criteria and guidelines of all corresponding non-interactive local coverage determinations are applicable when performing an interactive psychiatric services procedure code.

Section I: The Interactive Psychiatric Diagnostic Interview (CPT Code 90802)

CPT Code 90802 is a procedure code for the use of interactive techniques when performing the diagnostic evaluation. The interactive technique is used principally to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. This code includes the same components as the Psychiatric Diagnostic Interview Examination, which includes history, mental status, disposition, and other components as indicated. However, in the interactive examination, the physician uses inanimate objects such as toys and dolls for a child, or an interpreter for a deaf person or one who does not speak English. The medical record must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels.

Section II: Interactive Individual Psychotherapy (CPT Codes 90810—90815, 90823-90829)

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. Psychotherapy services, must be performed by a person licensed by the State where practicing, and who’s training and scope of practice allows that person to perform such services. 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. Refer to LCD A90804 Individual Psychotherapy

Psychotherapy sessions of approximately 75 to 80 minutes (Codes 90814 and 90828) should not be routinely used and should be reserved for exceptional circumstances. Data analysis reveals the use of these codes is not standard of practice. Therefore, Medicare does not view these codes as routine. Providers must clearly document medical necessity and define these exceptional services in the patient’s medical record.

Section III: Interactive Group Psychotherapy (CPT Code 90857)

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). Refer to LCD A90853 Group

Psychotherapy.

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 0914 Behavioral Health Treatment/Services - Individual Therapy 0915 Behavioral Health Treatment/Services - Group Therapy

CPT/HCPCS Codes

90802 INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF COMMUNICATION

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90810 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90811 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH

MEDICAL EVALUATION AND MANAGEMENT SERVICES

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90812 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90813 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH

MEDICAL EVALUATION AND MANAGEMENT SERVICES

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90814 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90815 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR

OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH

MEDICAL EVALUATION AND MANAGEMENT SERVICES

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90823 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL,

PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE

WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90824 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL,

PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE

WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90826

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90827 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL,

PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE

WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90828 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL,

PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE

WITH THE PATIENT;

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE 90829 INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL,

PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE

WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES 90857 INTERACTIVE GROUP PSYCHOTHERAPY

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

318.1 MODERATE INTELLECTUAL DISABILITIES

318.2 SEVERE INTELLECTUAL DISABILITIES

318.3 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

Note: All documentation for interactive psychiatric services must clearly reflect the requirements of the corresponding non-interactive procedure codes. Documentation to support the medical necessity for an interactive psychiatric services procedure code should be in addition to these guidelines. Any time the interactive methodology is chosen over the non-interactive, the medical record must clearly support the rationale for this approach. Otherwise stated, there must be an explanation why verbal communication was not possible.

On a periodic basis, the patient’s capacity to participate and benefit from psychotherapy should be documented. Such periodic 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 will reflect adjustments in the treatment plan that reveals the dynamics of treatment.

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 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

• A detailed summary of the 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 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 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 patients’ 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 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 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. (1995). Practice guideline for psychiatric evaluation of adults. Retrieved August 30, 2005 [Online] http://www.psych.org/psych_pract/treatg/pg/pg_adult.cfm. Provides the documentation requirements for a psychiatric evaluation.

American Psychiatric Association (2005). Treating Alzheimer’s Disease and other Dementias of Late Life. Retrieved August 30, 2005 [Online]

American Psychiatric Association. (2000). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, Second Edition. Retrieved August 23, 2005 [Online] at: http://www.psych.org/psych_pract/treatg(pg)Depression2e.book.cfm

Ingenix. (2005). Coding and Payment Guide, Behavioral Health Services. (5th ed.). Ingenix Incorporated

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/

AMA. (2006). CPT 2006 Current Procedural Terminology. (Professional Edition). American Medical Association.

Advisory Committee Meeting Notes

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 (L28893) replaces LCD L24030 as the policy in notice. This document (L28893) 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 0914 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.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

90810 descriptor was changed in Group 1 90811 descriptor was changed in Group 1 90812 descriptor was changed in Group 1 90813 descriptor was changed in Group 1 90814 descriptor was changed in Group 1 90815 descriptor was changed in Group 1 90823 descriptor was changed in Group 1 90824 descriptor was changed in Group 1 90826 descriptor was changed in Group 1 90827 descriptor was changed in Group 1 90828 descriptor was changed in Group 1 90829 descriptor was changed in Group 1

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

Reason for Change