LCD Reference Article Billing and Coding Article

Billing and Coding: Outpatient Psychotherapy

A59723

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A59723
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Outpatient Psychotherapy
Article Type
Billing and Coding
Original Effective Date
10/20/2024
Revision Effective Date
10/20/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

42 CFR §410.73-§410.76 Coverage of services provided by social workers, physician assistants, nurse practitioners, or clinical nurse specialists.

CMS Internet-Only Manual, Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, §160 Clinical Psychologist Services, §170 Clinical Social Worker (CSW) Services, §180 Nurse-Midwife (CNM) Services, §190 Physician Assistant (PA) Services, §200 Nurse Practitioner (NP) Services and §210 Clinical Nurse Specialist (CNS) Services

CMS Internet-Only Manual, Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, §110 Physician Assistant (PA) Services Payment Methodology, §120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology, §120.1 Limitations for Assistant-at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists, §150 Clinical Social Worker (CSW) Services, §160 Independent Psychologist Services, §170 Clinical Psychologist Services, §170.1 Payment and §210 Outpatient Mental Health Treatment Limitation

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Psychotherapy L39853.

General Coding

Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases.

Providers referenced; physicians, nonphysicians (clinical psychologists, independent psychologists, NPs, PAs, CNMs, etc.), provide services within the scope of their state license and clinical practice/education.

Individual Psychotherapy CPT® codes should only be used when focus of treatment is on individual psychotherapy.

Psychiatric service CPT® codes should not be used when other CPT® codes, such as an evaluation and management (E/M) service or pharmacologic code is more appropriate.

Interactive Complexity (90785) is an add-on code specific for psychiatric services. It refers to communication difficulties during a psychiatric procedure. This code is to be reported in conjunction with other codes (90791-90792, 90832-90834, 90836-90838, 90853) and is excluded when coding for the following: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T, 90839,90840, 96136-96139, 96146, 96130-96133.

Communication difficulties include:

  • Other individual responsible for the care of the patient, adults with guardians.
  • A request for another individual to be involved with care during a visit, such as family members, interpreter or translator.
  • Requiring the participation of a third party.

Interactive Complexity may be reported with:

  • The need to manage maladaptive communication (related to anxiety, high reactivity, repeated questions, etc.) among participants, complicating delivery of care.
  • Caregiver emotion/behavior interfering with delivery of care.
  • Reporting to a third party, such as negligence or abuse, initial evidence/disclosure of a sentinel event with patient and visit participants.
  • Overcoming language barriers.

This code is not to be reported in conjunction with crisis codes 90839, 90840.

Psychotherapy codes 90832, 90834 and 90837 refer to psychotherapy without medical management.

90833, 90836, 90838 are for psychotherapy with medical E/M. These are add-on codes in addition to the appropriate E/M codes. E/M codes alone do not include psychotherapy services.

For psychotherapy sessions greater than 90 minutes, medical records must document face-to-face time spent with the patient and medical necessity to be reimbursed.

Psychotherapy codes 90846 and 90847 refer to family psychotherapy. These codes do not pertain to history taking or E/M counseling services. This does not include the supervision of therapy by professional caretaker or staff.

Psychotherapy code 90853 refers to group therapy. If medically necessary, code 90785, medical complexity, may be billed in conjunction with this code.

Psychotherapy crisis code is 90839, first 60 minutes. Code 90840 is for each additional 30 minutes. These are standalone codes, 90840 must be billed with 90839.

Biofeedback is not a service covered by Medicare for psychosomatic disorders.

 

Billing Guidelines

If coding for both E/M services and psychotherapy services, the two services must be significant and separately identifiable.

For the same date of service, there is no requirement for a separate diagnosis.

Site of service is not always applicable to psychotherapy; psychotherapy codes are applicable in all settings.

 

Documentation Requirements

  • Time spent in the psychotherapy encounter as well as the therapeutic interventions (behavioral modification, supportive interaction, interpretive interactions) utilized to encourage therapeutic change.
  • Behavioral modification is not a separate service; it is an adjunct to psychotherapy.
  • Periodic summary of goals
  • Progress toward the goals set
  • Updated treatment plans, generally, every three months, should include estimated duration of treatment and treatment goals, the targeted symptoms should be outlined, and the treatment goals related to behavioral changes, though processes and /or medications detailed.
  • Presence of a psychiatric illness and/or a demonstration of emotional/behavioral symptoms sufficient to alter base-line functioning.
  • Detailed summary of the session including: therapeutic intervention, degree of patient interaction and participation as well as documentation of the goal-oriented outcomes and any progression or lack thereof in the patient’s symptoms/ behavior.
  • In a Family psychotherapy session without the patient present, there must be documentation of themes addressed in the session, descriptive documentation of the therapeutic interventions, the degree of patient participation and interaction with the family members, the reaction to the group, the group’s reaction to the patient and any changes/lack of changes in patient symptoms and/or behavior as a result of the therapy session.
  • Documentation is not to include privileged information.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(69 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
F01.A0 Vascular dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F01.A11 Vascular dementia, mild, with agitation
F01.A18 Vascular dementia, mild, with other behavioral disturbance
F01.A2 Vascular dementia, mild, with psychotic disturbance
F01.A3 Vascular dementia, mild, with mood disturbance
F01.A4 Vascular dementia, mild, with anxiety
F01.B0 Vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F01.B11 Vascular dementia, moderate, with agitation
F01.B18 Vascular dementia, moderate, with other behavioral disturbance
F01.B2 Vascular dementia, moderate, with psychotic disturbance
F01.B3 Vascular dementia, moderate, with mood disturbance
F01.B4 Vascular dementia, moderate, with anxiety
F01.C0 Vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F01.C11 Vascular dementia, severe, with agitation
F01.C18 Vascular dementia, severe, with other behavioral disturbance
F01.C2 Vascular dementia, severe, with psychotic disturbance
F01.C3 Vascular dementia, severe, with mood disturbance
F01.C4 Vascular dementia, severe, with anxiety
F04 Amnestic disorder due to known physiological condition
F05 Delirium due to known physiological condition
F06.0 Psychotic disorder with hallucinations due to known physiological condition
F06.1 Catatonic disorder due to known physiological condition
F06.2 Psychotic disorder with delusions due to known physiological condition
F06.31 Mood disorder due to known physiological condition with depressive features
F06.32 Mood disorder due to known physiological condition with major depressive-like episode
F06.33 Mood disorder due to known physiological condition with manic features
F06.34 Mood disorder due to known physiological condition with mixed features
F06.4 Anxiety disorder due to known physiological condition
F06.70 Mild neurocognitive disorder due to known physiological condition without behavioral disturbance
F06.71 Mild neurocognitive disorder due to known physiological condition with behavioral disturbance
F06.8 Other specified mental disorders due to known physiological condition
F10.10 Alcohol abuse, uncomplicated
F10.11 Alcohol abuse, in remission
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.130 Alcohol abuse with withdrawal, uncomplicated
F10.131 Alcohol abuse with withdrawal delirium
F10.132 Alcohol abuse with withdrawal with perceptual disturbance
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.20 Alcohol dependence, uncomplicated
F10.21 Alcohol dependence, in remission
F10.220 Alcohol dependence with intoxication, uncomplicated
F10.221 Alcohol dependence with intoxication delirium
F10.230 Alcohol dependence with withdrawal, uncomplicated
F10.231 Alcohol dependence with withdrawal delirium
F10.232 Alcohol dependence with withdrawal with perceptual disturbance
F10.24 Alcohol dependence with alcohol-induced mood disorder
F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions
F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations
F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder
F10.27 Alcohol dependence with alcohol-induced persisting dementia
F10.280 Alcohol dependence with alcohol-induced anxiety disorder
F10.281 Alcohol dependence with alcohol-induced sexual dysfunction
F10.282 Alcohol dependence with alcohol-induced sleep disorder
F10.288 Alcohol dependence with other alcohol-induced disorder
F34.0 Cyclothymic disorder
F34.1 Dysthymic disorder
F34.81 Disruptive mood dysregulation disorder
F34.89 Other specified persistent mood disorders
F48.1 Depersonalization-derealization syndrome
F48.2 Pseudobulbar affect
F48.8 Other specified nonpsychotic mental disorders
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

ICD-10 codes must be coded to the highest level of specificity.

Group 1 Codes

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ICD-10-PCS Codes

Group 1

(22 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
GZ2ZZZZ Crisis Intervention
GZ50ZZZ Individual Psychotherapy, Interactive
GZ51ZZZ Individual Psychotherapy, Behavioral
GZ52ZZZ Individual Psychotherapy, Cognitive
GZ53ZZZ Individual Psychotherapy, Interpersonal
GZ54ZZZ Individual Psychotherapy, Psychoanalysis
GZ55ZZZ Individual Psychotherapy, Psychodynamic
GZ56ZZZ Individual Psychotherapy, Supportive
GZ58ZZZ Individual Psychotherapy, Cognitive-Behavioral
GZ59ZZZ Individual Psychotherapy, Psychophysiological
GZ72ZZZ Family Psychotherapy
GZHZZZZ Group Psychotherapy
HZ50ZZZ Individual Psychotherapy for Substance Abuse Treatment, Cognitive
HZ51ZZZ Individual Psychotherapy for Substance Abuse Treatment, Behavioral
HZ52ZZZ Individual Psychotherapy for Substance Abuse Treatment, Cognitive-Behavioral
HZ54ZZZ Individual Psychotherapy for Substance Abuse Treatment, Interpersonal
HZ55ZZZ Individual Psychotherapy for Substance Abuse Treatment, Interactive
HZ56ZZZ Individual Psychotherapy for Substance Abuse Treatment, Psychoeducation
HZ57ZZZ Individual Psychotherapy for Substance Abuse Treatment, Motivational Enhancement
HZ58ZZZ Individual Psychotherapy for Substance Abuse Treatment, Confrontational
HZ59ZZZ Individual Psychotherapy for Substance Abuse Treatment, Supportive
HZ5BZZZ Individual Psychotherapy for Substance Abuse Treatment, Psychoanalysis
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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/20/2024 R1

Under CPT/HCPCS Codes Group 1: Paragraph removed verbiage “Codes 0821T and 0822T, code first 0820T”. Under CPT/HCPCS Codes Group 1: Codes deleted 90875, 90876, and 90880.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39853 - Outpatient Psychotherapy
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/14/2024 10/20/2024 - N/A Currently in Effect You are here
08/29/2024 10/20/2024 - N/A Superseded View

Keywords

  • Outpatient psychotherapy