LCD/NCD Portal

L29264 PSYCHIATRIC DIAGNOSTIC EVALUATION

 

 

01/01/2013

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Psychiatric diagnostic evaluations will be considered 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, which may be suggestive of a psychiatric illness.

• This examination may also be medically necessary when baseline functioning is altered by suspected illness or symptoms.

• It is appropriate for dementia, in patients who experience a sudden and rapid change in behavior.

• The psychiatric diagnostic evaluation is NOT considered to be medically reasonable and necessary:

o When it is 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 defect to prevent effective communication and the ability to assess the patient.

o When the patient has a previously established diagnosis of a neurological condition or dementia and is not amenable to the evaluation and therapy;

 unless there has been an acute and/or marked mental status change,

 a request for second opinion, or

 Diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

o When a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed.

 Routine performance of additional psychiatric diagnostic evaluation of patients with chronic conditions is NOT considered medically necessary.

• A psychiatric diagnostic evaluation can be conducted once, at the onset of an illness or suspected illness.

• The same provider may repeat it for the same patient

o if an extended hiatus in treatment occurs,

o if the patient requires admission to an inpatient status for a psychiatric illness or

o For a significant change in mental status requiring further assessment.

• An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition.

• A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been

o an acute and/or marked mental status change or

o A second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

 

 

CPT/HCPCS Codes

 

xx000 Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity

 

N/A

XX000 Not Applicable

 

 

Documentation Requirements

 

• Medical record documentation maintained by the provider must indicate the medical necessity of the psychiatric diagnostic evaluation.

• The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms which may be suggestive of a psychiatric illness or are sufficient to significantly alter baseline functioning and the diagnostic evaluation report which includes:

o The reason for the evaluation/patient’s chief complaint

o A referral source (if applicable)

o History of present illness, including length of existence of problems/symptoms/conditions

o Past history (psychiatric)

o Significant medical history and current medications

o Social history

o Family history

o Mental status exam

o Strengths/liabilities

o Multi-axis diagnosis or diagnostic impression list-including problem list

o Treatment plan including:

 methods of therapy,

 anticipated length of treatment to the extent possible, and

 a description of the planned goals related to expected changes in behavior or thought processes

• In circumstances where other informants (family or other sources) are interviewed in lieu of the patient, documentation must include the elements outlined previously, as well as the specific reason(s) for not evaluating the patient.

o Any notations where family members provided patient history should be included. This should be a rare occurrence.

 

 

Utilization Guidelines

 

• A psychiatric diagnostic evaluation should be conducted once, at the onset of an illness or suspected illness and by each provider group involved in the initial therapeutic treatment plan.

• It would not be expected that partners within the same group or organization, and/or partners in care with accessible records (such as fax capabilities) would each perform an individual diagnostic evaluation at the beginning of treatment.

• It may be utilized again for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness or to other residential status wherein a new provider group establishes care.

• An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition.

• A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established diagnosis of a neurological disorder or dementia and there has been an acute and/or marked mental status change or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

• Routine performance of additional psychiatric diagnostic evaluation of patients with chronic conditions is not considered medically necessary.

 

 

Treatment Logic

 

• A psychiatric diagnostic evaluation consists of elicitation of

o a complete medical history (to include past, family and social);

o psychiatric history,

o a complete mental status exam,

o establishment of a tentative diagnosis, and

o An evaluation of the patient's ability and willingness to participate in the proposed treatment plan.

o Information may be obtained from the patient, other physicians, other clinicians or community providers, and/or family members.

o There may be overlapping of the medical and psychiatric history depending upon the problem(s).

• Although the emphasis, types of details, and style of a psychiatric evaluation differ from the medical evaluation, the purpose is the same: to establish effective communication with interaction of sufficient quality between provider and patient to gather accurate data in order to formulate tentative

 

 

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

 

01/01/2013

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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 PSYCHIATRIC DIAGNOSTIC EVALUATION