L29264-LCD

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Local Coverage Determination (LCD) for Psychiatric Diagnostic Interview Examination (L29264)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29264

LCD Title Psychiatric Diagnostic Interview Examination

Contractor's Determination Number 90801

Primary Geographic Jurisdiction 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 02/02/2009 Original Determination Ending Date

Revision Effective Date

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 Transmittal 98, Change Request 3457

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

Program Memorandum AB-02-160 (Change Request 2403), dated 11/08/2002 CR 2403, Medicare Telehealth Update, dated February 12, 2003

Program Memorandum AB-03-070 (Change Request 2734), dated 05/09/2003

CMS Manual System, Pub. 100-1, Medicare General Information, Chapter 3, Section 30-30.3 CMS Manual System Pub 100-4, Medicare Claims Processing, Chapter 12, Section 210-210.1

Indications and Limitations of Coverage and/or Medical Necessity

A psychiatric diagnostic interview examination consists of elicitation of a complete medical history (to include past, family and social); psychiatric history, a complete mental status exam, establishment of a tentative diagnosis, and an evaluation of the patient's ability and willingness to participate in the proposed treatment plan. Information may be obtained from the patient, other physicians, other clinicians or community providers, and/or family members. 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 interview differ from the medical interview, 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 diagnoses, determine necessity and as appropriate initiate an effective and comprehensive treatment plan.

Medicare will consider the psychiatric diagnostic interview examination 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, 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 interview examination is not considered to be medically reasonable and necessary

• 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.

• When the patient has a previously established diagnosis of a neurological condition or dementia and is not amenable to the interview 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.

• 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 interview exams of patients with chronic conditions is not considered medically necessary.

A psychiatric diagnostic interview can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it 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 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 interview may also be utilized again if the patient has a previously established 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.

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

90801 PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

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

Medical record documentation maintained by the provider must indicate the medical necessity of the psychiatric diagnostic interview examination.

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 interview examination report which includes:

• The reason for the interview/patient’s chief complaint

• A referral source (if applicable)

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

• Past history (psychiatric)

• Significant medical history and current medications

• Social history

• Family history

• Mental status exam

• Strengths/liabilities

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

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

Appendices

Utilization Guidelines A psychiatric diagnostic interview 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 interview examination 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 interview 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 interview examinations of patients with chronic conditions is not

considered medically necessary.

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

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD 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 Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29264) replaces LCD L6264 as the policy in notice. This document (L29264) is effective on 02/02/2009.

Reason for Change