LCD/NCD Portal
Automated World Health
L30351
PHARMACOLOGIC MEDICATION MANAGEMENT FOR PSYCHOTHERAPY SERVICES
10/01/2011
Indications and Limitations of Coverage and/or Medical Necessity
Indications
• CPT code 90862, pharmacologic medication management, is intended for use by the physician, or master’s prepared psychiatric nurse with state authorized prescribing privileges who is prescribing pharmacological therapy for a patient with any psychiatric disorder.
o Pharmacologic medication management involves the assessment, monitoring and prescribing of psychopharmacologic medication and includes no more than minimal psychotherapy.
o Psychopharmacologic medication management should only be reported when the qualified clinician is providing in-depth evaluation and monitoring of psychopharmacologic medication and is personally coordinating medication decisions with the patient in a face-to-face encounter.
• The primary focus of the pharmacologic medication management visit is the management of psychotropic medication, including monitoring for withdrawal syndrome or worsening of the psychiatric condition of the patient.
o This visit may also include minimal medical psychotherapy.
o Minimal medical psychotherapy is a face-to-face medical psychotherapy encounter and is usually a supportive modality.
• HCPCS code M0064 involves monitoring or changing psychopharmacologic medication, and is intended for use by the physician, physician’s assistant, or advanced registered nurse with psychiatric training and acting within the scope of practice as previously described, during a face-to-face encounter with the patient without providing any psychotherapy.
o HCPCS code M0064 represents a brief office visit for patients that need simple dosage adjustments of long-term medication, continuation of current medication regimens without in-depth evaluation of the medication effectiveness on the patient’s mental condition and/or tolerance to the medication.
Limitations
• Psychopharmacological management (CPT code 90862) refers to the in-depth management of psychopharmacologic agents and represents a skilled aspect of patient care, which includes no more than minimal medical psychotherapy.
o The in-depth management of the psychopharmacologic medication is the focus of the visit, which also may include minimal medical psychotherapy.
o Lesser level of drug monitoring, such as simple prescription renewal with minimal management, without providing psychotherapy, should be reported under HCPCS code M0064.
• The pharmacological medication management codes (CPT code 90862 and HCPCS code M0064) are not intended to be used for the administration of medication, nor are they intended to be used for observation of the patient taking oral medication.
o Administration and supply of oral medication is a noncovered service.
• If the patient receives more than minimal medical psychotherapy and psychopharmacologic management occurs during the same visit, the drug management is included in the psychotherapy code, as part of the service by definition, and CPT code 90862 should not be reported in addition to the psychotherapy code.
• Psychopharmacologic management, represented by CPT code 90862 or HCPCS code M0064 should not be reported on the same day as CPT codes 90801, 90804 – 90829, 90845, 90847, 90849, 90853, or 90857.
• If the clinician provides evaluation and management (E/M) services beyond the scope of the description for CPT code 90862, and psychopharmacologic management during the same visit, only the E/M codes may be reported.
o It is not appropriate to report CPT code 90862 on the same day as E/M services.
• HCPCS code M0064 is intended to report medication management of a clinically stable patient.
o The intent of M0064 is the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic and personality disorders.
CPT/HCPCS Codes
90862 PHARMACOLOGIC MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND REVIEW OF MEDICATION WITH NO MORE THAN MINIMAL MEDICAL PSYCHOTHERAPY
M0064 BRIEF OFFICE VISIT FOR THE SOLE PURPOSE OF MONITORING OR CHANGING DRUG PRESCRIPTIONS USED IN THE TREATMENT OF MENTAL PSYCHONEUROTIC AND PERSONALITY DISORDERS
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
• Medical record documentation maintained by the provider must substantiate the medical necessity of the treatment.
o The medical record should be clear and include the reason for the treatment, its frequency, the service that was performed, and the outcome or effectiveness of the treatment.
• In order to report CPT code 90862, the progress note must support that in-depth psychopharmacologic management with minimal psychotherapy was provided.
o Examples of documentation to support that the specifications of CPT code 90862 were performed include, but are not limited to the following:
The patient’s diagnosis
And
Pertinent signs and symptoms of the patient’s condition;
And
The medications that are prescribed and being managed and their dosages;
And
The patient’s response to the medication treatment;
And
The rationale for maintaining or changing the drug regimen;
And
An interval history that includes any pertinent changes since the last encounter (e.g., medication side effects, drug interactions, drug allergies, withdrawal symptoms);
And
The ordering/reviewing of pertinent laboratory studies;
And
Relevant patient/family education;
And
Patient treatment plans and goals documented in the initial progress note with any changes in the plan of care documented in subsequent progress notes.
When psychotherapy is provided, the provider must be aware of the following information:
• According to 45 CFR §164.501 Psychotherapy notes are defined as “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.
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 circumstance shall a contractor request a provider to submit notes defined in 45 CFR §164.501.
o 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. If the provider does not support sufficient information to demonstrate that services were actually medically necessary, the claim will be denied.
• The following information is excluded from the protected information in 45 CFR §164.501, and must be included in all psychiatric medical record documentation and made available upon request:
o Name of beneficiary and date of service
o Type of service
o Medication prescription and monitoring
o Time element, where duration of the face-to-face contact is the determining factor for coding the service rendered
o Modalities and frequency of treatment furnished
o A clinical note for each encounter that summarizes the diagnosis, symptoms, functional status, mental status, treatment plan, prognosis, and progress to date of the patient.
• 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.
Treatment Logic
• The primary focus of the pharmacologic medication management visit is the management of psychotropic medication, including monitoring for withdrawal syndrome or worsening of the psychiatric condition of the patient.
• This visit may also include minimal medical psychotherapy.
• Minimal medical psychotherapy is a face-to-face medical psychotherapy encounter and is usually a supportive modality.
Sources of Information and Basis for Decision
American Medical Association. (2009). Current Procedural Terminology, Professional Edition.
American Medical Association. (2006). CPT 2006 Changes, An Insider’s View.
American Psychiatric Association. (2002). Psychotherapy Notes Provision of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule Resource Document. Retrieved April 3, 2009 via Internet: www.americanpsychiatricassociation.com
American Psychiatric Association. (2005). Treating Alzheimer’s Disease and Other Dementias of Late Life. Retrieved April 9, 2009 via Internet: www.americanpsychiatricassociation.com
American Academy of Family Physicians. (2004). Family Practice Management. Answers to your questions. CPT’s pharmacologic management code. Retrieved April 9, 2009 via Internet: www.americanpsychiatricassociation.com
National Guideline Clearinghouse. (2008). Practice guideline for major depression in adults in primary care. Retrieved May 8, 2009 via Internet: http://www.guidleine.gov
National Guideline Clearinghouse. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Retrieved May 8, 2009 via Internet: http://www.guidleine.gov
Other Medicare Administrative Contractor’s (MAC) Local Coverage Determinations (LCDs).
10/01/2011
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 L30351 Pharmacologic Medication Management for Psychotherapy Services