Local Coverage Determination (LCD)

Home Health - Psychiatric Care

L34561

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Contractor Information

LCD Information

Document Information

LCD ID
L34561
LCD Title
Home Health - Psychiatric Care
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 12/03/2020
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1814(a)(2)(C) Requirements of requests and certifications

Title XVIII of the Social Security Act, §1835(a)(2)(A) Procedure for payment of claims of providers of services

42 CFR §409.42-Beneficiary qualifications for coverage of services

42 CFR §409.43 Plan of care requirements

42 CFR §424.22 Requirements for Home Health Services

CMS Internet-Only Manual, Pub 100-01, Medicare General Information Eligibility, and Entitlement Manual, Chapter 4, §30.1 Content of the Physician's Certification

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.5.1.1 Face-to-Face Encounter, §40.1.1 General Principles Governing Reasonable and Necessary Skilled Nursing Care, §40.1.2.3 Teaching and Training Activities, §40.1.2.15 Psychiatric Evaluation, Therapy, and Teaching, §40.1.3 Intermittent Skilled Nursing Care, §40.2.1 General Principles Governing Reasonable and Necessary Therapy, Speech-Language Pathology Services, and Occupational Therapy, and §50.3 Medical Social Services

CMS Internet-Only Manual, Pub 100-08, Medicare Integrity Program Manual, Chapter 6, §6.2 Medical Review of Home Health Services, §6.2.1 Physician Certification of Patient Eligibility for the Medicare Home Health Benefit, §6.2.1.1 Certification Requirements, §6.2.2 Physician Recertification, §6.2.2.1 Recertification Elements, §6.2.3 The Use of the Patient's Medical Record Documentation to Support the Home Health Certification, §6.2.4 Coding, §6.2.5 Medical Necessity of Services Provided, §6.2.6 Examples of Sufficient Documentation Incorporated Into a Physician's Medical Record, and §6.2.7 Medical Review of Home Health Demand Bills

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Skilled nursing services must be based on the patient's medical condition as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual,(IOM),Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, §40.1.1.

The evaluation, psychotherapy and teaching activities needed by patients suffering from a diagnosed psychiatric disorder requiring active treatment by a psychiatrically trained nurse may be covered as skilled nursing services. Patients may also require medical social services, occupational therapy (OT), home health aide visits or other home health (HH) services related to the treatment of their psychiatric diagnosis.

If all other eligibility and coverage requirements under the HH benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse (RN) are necessary.

HH clinical notes must document as appropriate the following:

1. The patient must be confined to the home.

The condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving the home would require a considerable and taxing effort.

A patient with a psychiatric disorder is considered to be homebound "... if his/her illness is manifested in part by a refusal to leave the home, or is of such a nature that it would not be considered safe for him/her to leave home unattended even if he/she has no physical limitations."

The following conditions support the homebound determination:

  1. Agoraphobia, paranoia or panic disorder
  2. Disorders of thought processes wherein the severity of delusions, hallucinations, agitation and/or impairment of thoughts/cognition grossly affect the patient’s judgment and decision making, and therefore the patient’s safety
  3. Acute depression with severe vegetative symptom
  4. Psychiatric problems associated with medical problems that render the patient homebound.

If a patient does in fact leave the home, the patient may, nevertheless, be considered homebound if the absences from the home are infrequent or for relatively short duration, or are attributable to the need to receive medical treatment.

2. Services must be provided under a HH Plan of Care (POC) approved and signed by the treating physician.

3. Nursing services provided must meet the part-time or intermittent requirements for HH services. "In most instances, this definition will be met if a patient requires a skilled nursing service at least every 60 days."

4. Services must be reasonable and necessary for treating the patient's psychiatric diagnosis and/or symptoms.

5. The services of a skilled psychiatric nurse must be required to provide the necessary care, i.e., observation/assessment, teaching/training activities, management and evaluation of a patient care plan, or direct patient care of a diagnosed psychiatric condition which may include behavioral/cognitive interventions.

6. Further guidance on required documentation may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.15.

Note: Psychiatric nursing must be furnished by an agency that does not primarily provide care and treatment of mental disorders. These agencies are precluded from participating as Medicare HH agencies.

QUALIFICATIONS FOR PSYCHIATRICALLY TRAINED NURSES PROVIDING PSYCHIATRIC EVALUATION AND THERAPY IN THE HOME

1. Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse (RN). The services of the psychiatric nurse are to be provided under a POC established and reviewed by a physician.

2. Palmetto GBA would consider the special training and/or experience requirements to be met, if the RN meets one of the following criteria:

  1. A RN with a Master’s degree with a specialty in psychiatric or mental health nursing and licensed in the state where practicing would qualify. The RN must have nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
  2. A RN with a Bachelor’s degree in nursing and licensed in the state where practicing would qualify. The RN must have 1 year of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
  3. A RN with a Diploma or Associate degree in nursing and licensed in the state where practicing would qualify. The RN must have 2 years of recent nursing experience (recommended within the last 3 years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.

3. It is highly recommended that psychiatric RNs also have medical/surgical nursing experience, because many psychiatric patients meet homebound criteria due to a physical illness.

4. Nurses with these qualifications would meet the requirements necessary to provide psychiatric evaluation and therapy to Medicare HH patients. The services of a psychiatric nurse are to be provided under a POC established and reviewed by the treating physician.

5. For additional information, see the BILLING WHEN SEPARATE VISITS WERE MADE FOR MEDICAL AND PSYCHIATRIC NURSING CARE section of the Billing and Coding: Home Health - Psychiatric Care A56756 article.

Diagnostic Criteria

1. The patient must be under the care of a physician who is qualified to sign the physician’s certification and recertify the POC at least every 60 days (2 months). The physician's evaluation and subsequent recertifications must become part of the patient's medical record.

2. If the skills of a psychiatric RN are required, the service must be reasonable and necessary and intermittent.

3. Reasonable goals must be established, and there must be a reasonable expectation that the goals will be achieved. Decreasing and/or shortening inpatient and emergency room care may be a goal for the psychiatric patient's POC.

Home Health Plan of Care

The POC for a psychiatric patient must be completed. Emphasis must be placed on documentation of mental status and those skills necessary to treat the psychiatric diagnosis.

Psychiatric Interdisciplinary Team's Role

Physician

1. Certifies/Recertifies the patient’s homebound status.

2. Approves HH POC, which must be signed and dated prior to the HH agency billing for services.

3. Prescribes medications as necessary.

4. Provides supplemental orders when medically necessary.

Skilled Nursing Care

Registered Psychiatric Nurse

1. Makes initial assessment visit utilizing observation/assessment skills.

2. Manages medical illness per POC; performs psycho-biological interventions.

3. Evaluates, teaches and reviews medications and compliance; administers intramuscular (IM) or intravenous (IV) medication.

4. Manages situational or other crises; performs assessments of potential self-harm or harm to others, and refers to the treating physicians as necessary.

5. Teaching and training activities that require skilled nursing personnel to teach a patient, the patient's family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.

  • Teaches self-care, mental and physical well-being, promotes independence and patient’s rights.

The CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.

6. Promotes and encourages patient/caregiver to maintain a therapeutic environment.

7. Provides supportive counseling psychotherapy and psycho-therapeutic interventions according to education and licensure. Provides psycho-education, such as teaching/training with disease process, symptom and safety management, coping skills and problem solving.

8. Provides evaluation and management of the patient's care plan.

9. Counseling services may be rendered by either a trained psychiatric nurse or a social worker. These services should not be duplicative. Concurrent counseling or psychotherapy services by multiple providers are not medically necessary.

10. Although intervention with family members may be appropriate on occasion, services by a trained psychiatric nurse to family members are not covered as a HH benefit, even if the patient will benefit.

Medical Social Services

Medical social services provided by a qualified medical social worker (MSW) or a social work assistant under the supervision of a qualified MSW, may be covered as HH services when all of the following apply:

  1. The patient meets the qualifying criteria for coverage of HH services.
  2. The services of these professionals are necessary to resolve social or emotional problems which are, or are expected to be, an impediment to the effective treatment of the patient's psychiatric condition or his/her rate of recovery.
  3. The POC clearly indicates that the skills of a qualified MSW (or a social worker assistant under the supervision of a qualified MSW) are required to safely and effectively provide the needed care.

When the above requirements are met, coverage for social worker visits may include, but are not limited to the following:

  1. Assessment of the need for care related to the social and emotional factors associated with the patient's illness, the actual need for care, adjustment to the care and the response to the treatment along with the assessment of the patient's financial resources, home situation, and the availability of community resources.
  2. Counseling services that are required by the patient for the treatment of their psychiatric condition (Psychotherapy services, constituting active treatment of the psychiatric condition, may be provided by MSWs).
  3. Brief counseling (2 or 3 visits) of the patient's family or care-giver(s) when they are reasonable and necessary to resolve problems that are a clear and direct impediment to the treatment of patient's illness or injury or rate of recovery.
  4. Appropriate action to obtain available community resources to assist in resolving the patient's problem.

Note: Medicare does not cover the services of an MSW to assist in filing the application for Medicaid or follow up on the application. Federal regulation requires the state to provide assistance in completing the application to anyone who chooses to apply for Medicaid.

Note: A patient may require separate and distinct services provided by a skilled psychiatric nurse and a MSW. However, care must be used to avoid duplication of services that could be provided by both of these disciplines, e.g., counseling of the patient.

Home Health Aide (HHA)

Home health aides may perform personal care or other covered HHA services.

Occupational Therapist (OT)

1. The skills of an occupational therapist may be required to decrease or eliminate limitations in functional activity imposed by psychiatric illness or disability. OTs may address factors which interfere with the performance of specific functional activities due to cognitive, sensory, psychosocial or perceptual deficits.

Additional guidance on these services and the accepted standards may be found in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

2. The skills of an OT to assess and reassess a patient’s rehabilitation needs and potential, or to develop and/or implement an OT plan are covered when they are reasonable and necessary because of the patient’s condition.

3. The planning, implementing and supervision of therapeutic programs (including, but not limited to those listed below) are skilled OT services. As such, these services are covered, if they are reasonable and necessary for the treatment of the patient's illness or injury.

a. Selecting and teaching task oriented, therapeutic activities designed to restore and increase cognitive abilities and functional participation in Activities of Daily Living (ADLs) and advanced ADLs

b. Planning, implementing and supervising therapeutic tasks and activities designed to restore sensory-integrative function

c. Planning, implementing and supervising of individualized therapeutic activity programs (as well as, adapting the environment) as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness

d. Assessing and planning for improved home safety.

Maintenance Program

Coverage of therapy services, including OT services, for a maintenance program is based on the individual's need for skilled care in that maintenance program as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

Concurrent Admission to Home Health and Partial Hospitalization Program

Because partial hospitalization services are intended to meet all of the patient's psychiatric care needs, patients admitted to a partial hospitalization program (PHP) are not generally considered appropriate for psychiatric HH services. Medical necessity must be substantiated on a case by case basis. If there are concurrent admissions, the HH claims will be reviewed to verify the medical necessity of the service(s) provided and that the homebound criterion is met.

Discharge Criteria

Patients should cease receiving psychiatric HH services when:

1. Physician orders discharge

2. Patient discontinues/refuses service with physician or nurse

3. Patient is not compliant with the treatment plan, despite appropriate provider interventions

4. Patient/family requests discharge

5. The treatment objectives and stated functional outcome goals have been attained or are no longer attainable

6. The patient is no longer homebound

7. Other appropriate discharge protocols, e.g., the patient moves or is transferring to another agency, etc.

8. A maintenance program is established, if appropriate.

Psychiatric Nursing in Group Setting
Group interventions for psychiatric HH patients are not covered under the HH benefit. The POC and treatment must be individualized.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

A clinical note must be written for each HH visit. The HH clinical notes must document as appropriate:

  • the history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and
  • the patient/caregiver’s response to the skilled services provided.

If a family member/caregiver is involved in the patient’s care, the documentation must also include this, and

  • the plan for the next visit based on the rationale of prior results,
  • a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
  • the complexity of the service to be performed, and
  • any other pertinent characteristics of the beneficiary or home.

Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:

  • Patient tolerated treatment well
  • Caregiver instructed in medication management
  • Continue with POC.

In order for HH patients to be eligible to receive services under the Medicare HH benefit, the following must be documented for certification/recertification:

a) Patient is under a physician's care
b) Homebound status-with documentation of confinement to home in medical records
c) Established POC-must be signed and dated by the certifying physician
d) Face-to-Face-no more than 90 days prior or 30 days after start of HH care
e) Skilled need-services must be medically necessary and documentation of the skilled need should be in the patients medical records.

If the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will not be covered- even if the requirements for recertifications are met. Recertifications are needed at least every 60 days, when there is a need for continuing home care.

1. Documentation must be legible, relevant and sufficient to justify the services billed. In general, services must be covered therapy services provided according to Medicare requirements.

2. Legible documentation should be brief and factual. Use descriptive charting: be problem-specific.

3. Legible documentation should clearly support the medical necessity for services.

4. Each visit note should include legible documentation of any psychiatric or medical assessment, an evaluation of the patient’s mental status, level of function and progress toward goals. Document objectively when describing behaviors and/or findings.

5. Legibly document changes in the patient’s condition and the actions taken, e.g., notification of the physician.

6. Legibly document the assessment of home milieu and supportive environment.

7. Teaching has to be directed at improving function. Document identified teaching needs in response to psychiatric symptoms. Document all patient/family education, the reason for education, what was taught, and the patient’s response. If repetitive teaching is required, documentation must clearly show the medical necessity of that teaching. Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record.

8. Document the patient’s understanding and compliance of the medication regimen and treatment plan, and how verified.

9. Document the administration of intramuscular (IM) and/or intravenous (IV) medications, their effectiveness, and any side effects of the patient's medication regime.

10. Document patient safety issues.

11. Documentation should show that periodic venipuncture for blood levels for psychiatric medications, such as Lithium, Tegretol, Clozaril and others, and other related laboratory work, are performed when necessary and pertinent reports of results are in the medical record. This ensures patient compliance and appropriate therapeutic levels. The frequency of testing should be consistent with acceptable standards of medical practice for continued monitoring of a diagnosis, medical problem, or treatment regimen. The HH record must document the rationale for the blood draw as well as the results of the test(s).

12. The person rendering the service must sign each visit note. If psychiatric services were rendered it must have been performed by a psychiatric RN.

Utilization Guidelines

1. For patients with Alzheimer’s disease, please refer to the Local Coverage Determination (LCD) Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances L34562.

2. The POC and/or Outcome and Assessment Information Set (OASIS) should include whether the therapy is rehabilitative/restorative or maintenance.

Sources of Information

N/A

Bibliography

American Psychiatric Association:Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, DSM-5™. Arlington, VA:American Psychiatric Association;2013.

 

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
12/03/2020 R18

Under CMS National Coverage Policy added section headings to the regulations. Punctuation and typographical errors were corrected throughout the LCD. Acronyms were defined and inserted where appropriate throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/10/2019 R17

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, §40.2 was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Home Health - Psychiatric Care A56756 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/01/2019 R16

All coding located in the Coding Information section has been moved into the related Billing and Coding: Home Health - Psychiatric Care A56756 article and removed from the LCD. 

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Home Health - Psychiatric Care A56756 article.

Formatting and punctuation errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.  

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
04/18/2019 R15

This revision is to correct the date for revision 14. The effective date should have been 4/18/2019.

  • Provider Education/Guidance
10/01/2018 R14

Under Coverage Indications, Limitations and/or Medical Necessity removed all quoted Internet Only Manual (IOM) text from the first paragraph and changed verbiage to read “Skilled nursing services must be based on the patient's medical condition as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual 100-02 Chapter 7 §40.1.1.” Additional italicized text was removed from this section and verbiage “Further guidance on required documentation may be found in the IOM 100-02 Chapter 7 §40.1.2.15.” was added. Under subheading Skilled Nursing Care all quoted IOM text was removed and replaced by “The IOM 100-02 Chapter 7 §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and on the appropriateness of re-teaching and re-training.” Under subheading Medical Social Services all quoted IOM text was removed and verbiage changed to”Assessment of the need for care related to the social and emotional factors associated with the patient's illness, the actual need for care, adjustment to the care and the response to the treatment along with the assessment of the patient's financial resources, home situation, and availability of community resources.” Under subheading Occupational Therapist (OT) all quoted IOM text was removed and “Additional guidance on these services and the accepted standards may be found in the IOM 100-02 Chapter 7 §40.2.1.” was inserted. Under subheading Maintenance Program removed all quoted IOM text and “Coverage of therapy services, including occupational therapy services, for a maintenance program is based on the individual's need for skilled care in that maintenance program as described in the IOM 100-02 Chapter 7 §40.2.1.” was inserted. Formatting and punctuation were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
10/01/2018 R13

Under Associated Contract Numbers, contract number 10311 was inadvertently added during the 2018 annual ICD-10 update. This contract number has been removed.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
10/01/2018 R12

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes the following revisions were made: ICD-10 code F53 has been deleted. The following ICD-10 codes have been added: F12.23, F12.93, F53.0, F53.1, T43.641A, T43.641D , T43.641S, T43.642A, T43.642D, T43.642S, T43.643A, T43.643D, T43.643S, T43.644A, T43.644D, T43.644S. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
02/22/2018 R11

Under Coverage Indications, Limitations and/or Medical Necessity corrected and added punctuation throughout this section.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
  • Typographical Error
10/01/2017 R10

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes the description was revised for ICD-10 code F41.0. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 code F50.82. This revision is due to the 2017 Annual ICD-10 Code Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
03/16/2017 R9 Under CMS National Coverage Policy Deleted Change Request 9369, Transmittal 3378, dated October 16, 2015 as this was manualized and is now found in the CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, §40.2. Deleted Change Request 9189, Transmittal 603, dated July 21, 2015 as this was manualized and is now found in the CMS Internet-Only Manual, Pub 100-08, Medicare Integrity Program Manual, Chapter 6, §§6.2, 6.2.1, 6.2.1.1, 6.2.2, 6.2.2.1, 6.2.3, 6.2.4, 6.2.5, 6.2.6 and 6.2.7.
  • Provider Education/Guidance
01/01/2017 R8 Under CPT/HCPCS Codes the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R7 Under ICD-10 Codes That Support Medical Necessity Group 1 added F32.89, F42.2, F42.4, F42.8, and F42.9. Under ICD-10 Codes That Support Medical Necessity Group 1 deleted F32.8, F34.8, and F42. This revision is due to the Annual ICD-10 Code Update.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
02/25/2016 R6 Under CMS National Coverage Policy added the first paragraph and added “Services” to 42 CFR §424.22. Under Coverage Indications, Limitations and/or Medical Necessity- Qualifications For Psychiatrically Trained Nurses Providing Psychiatric Evaluation And Therapy In The Home 2. a.b.c. replaced “An” to now read “A”. Under Coverage Indications, Limitations and/or Medical Necessity-Medical Social Services in the second paragraph-2. revised “individual’s” to now read “patient’s”. Under ICD-10 Codes That Support Medical Necessity-Group 1: Paragraph added “an”. Under Associated Information-Documentation Requirements language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals was italicized. Under Sources of Information and Basis for Decision the citation was placed in the AMA Citation format and added the place of publication.
  • Provider Education/Guidance
  • Typographical Error
  • Other
01/01/2016 R5 Under CMS National Coverage Policy added reference to CMS Internet-Only Manual, Pub 100-04 Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015.
Under CPT/HCPCS Codes section removed G0154 and added HCPCS codes G0299 & G0300.
  • Provider Education/Guidance
  • Public Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R4 Under CMS National Coverage Policy added the following: 42 CFR §424.22-Requirements for Home Health, 42 CFR §409.42-Beneficiary qualifications for coverage of services, §409.43 Plan of care requirements, Title XVIII of the Social Security Act, §1835 (a)(2)(A) Procedure for payment of claims of providers of services, Title XVIII of the Social Security Act, §1814 (a)(2)(C) Requirements of requests and certifications and CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Transmittal 603, dated July 21, 2015, Change Request 9189. Under Coverage Indications, Limitations and/or Medical Necessity- Diagnostic Criteria 1. revised “an” in the first sentence to now read “a”. Under ICD-10 Codes That Support Medical Necessity in the paragraph revised the cited reference DSM-IV TR to now read DSM-5™. Under Associated Information-Documentation Requirements added the requirements for certification/recertification.
  • Provider Education/Guidance
  • Other (Change Request 9189, Transmittal 603)
10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and revenue code removal)
10/01/2015 R2 Under Associated Information under utilization Guidelines, corrected L31532 to correspond to the ICD-10 version (L34562).
  • Typographical Error
10/01/2015 R1 Under CMS National Coverage Policy added additional citations for Pub 100-02, Chapter 7 sections: 40.1.2.3, 40.1.3, 40.2.4, 50.3. Removed section 40.4.1.2.3 as it was a typographical error.

Under Coverage Indications, Limitations, and/or Medical Necessity removed italics from entire policy and only italicized manual citation; in second paragraph, changed that requires to requiring; made some grammatical and punctuation corrections throughout section; under Skilled Nursing Care #2 added “per Plan of Care”.
Under Bill Type Codes removed 033x as per CR 8244.
Under Associated Information #11 added “of the test(s)”. Under subsection Utilization Guidelines #2 re-structured sentence to read “The plan of care and/or the OASIS should include whether the therapy is rehabilitative/restorative or maintenance”.
Under Sources of Information and Basis for Decision removed source for ISAD Health Services Corporation.
  • Provider Education/Guidance
  • Other (Annual Validation)

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56756 - Billing and Coding: Home Health - Psychiatric Care
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/24/2020 12/03/2020 - N/A Currently in Effect You are here
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Keywords

  • Home Health
  • Psychiatric Care

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