L30351-LCD

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Local Coverage Determination (LCD) for Pharmacologic Medication Management for Psychotherapy Services (L30351)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30351

LCD Title

Pharmacologic Medication Management for Psychotherapy Services

Contractor's Determination Number 90862

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 09/30/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2, 30.3 and 50;

Chapter 6, Section 70; Chapter 12, Sections 40.8 and 50

CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility and Entitlement, Chapter 5, Section 20.3-20.6

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.2

45 CFR §164.501 The Final HIPPA Privacy Rule

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. Pharmacologic medication management involves the assessment, monitoring and prescribing of psychopharmacologic medication and includes no more than minimal psychotherapy. 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. 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.

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. 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. The in-depth management of the psychopharmacologic medication is the focus of the visit, which also may include minimal medical psychotherapy. 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. 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. 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. The intent of M0064 is the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic and personality disorders.

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

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 - 294.9 opens in new window

295.00 - 299.91 opens in new window

300.00 - 316 opens in new window

SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE

SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE

ANXIETY STATE UNSPECIFIED - PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE

317 MILD INTELLECTUAL DISABILITIES 318.0 - 318.2 opens in new

window MODERATE INTELLECTUAL DISABILITIES - PROFOUND INTELLECTUAL DISABILITIES

331.0 ALZHEIMER'S DISEASE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the provider must substantiate the medical necessity of the treatment. 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. 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.” 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. 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. The refusal of a provider to submit such information shall not result in the denial of a claim.

If the medical record includes any of the information excluded from the definition of psychotherapy notes in

§164.501, as stated above, the provider is responsible for extracting the information required to support that the claim is reasonable and necessary. Contractors must review the claim using all supporting documentation submitted by the provider. If the provider does not 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:

• Name of beneficiary and date of service;

• Type of service;

• Medication prescription and monitoring;

• Time element, where duration of the face-to-face contact is the determining factor for coding the service rendered;

• Modalities and frequency of treatment furnished;

• 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). Contractors must request records related to the claim(s) being reviewed.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American 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). 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.

Florida Carrier Advisory Committee Meeting June 20, 2009.

Puerto Rico/U.S. Virgin Islands Carrier Advisory Committee Meeting June 25, 2009.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 08/15/2009

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Descriptor change for ICD-9-CM codes 317 and 318.0-

318.2. The effective date of this revision is based on date of service. Revision Number:Original

Start Date of Comment Period:06/01/2009 Start Date of Notice Period:08/15/2009 Original Effective Date:09/30/2009

LCR B2009-084

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change