LCD/NCD Portal

L29173

 

FAMILY PSYCHOTHERAPY

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• Family psychotherapy sessions may occur with or without the patient present.

o The process of family psychotherapy helps reveal a family’s repetitious communication patterns that are sustaining and reflecting the identified patient’s behavior.

o 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.

o 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:

o When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members; and/or

o 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.

o 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.

 

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 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. 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 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, and 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:

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 family 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 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.

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.

o 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).

o 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 \

o demonstrates the patient’s ability to effectively communicate with the therapist

o family members and interact with sufficient quality while working to improve or alleviate the emotional disturbances

o reverse or change maladaptive patterns of behavior and

o 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:

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

OR

o 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 Face to face 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 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.

o 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.

 

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

 

FCSO LCD 29173, Family Psychotherapy, 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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.

 

 

AMA CPT / ADA CDT 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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29173 Family Psychotherapy