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This medical policy (medical coverage guideline) is Copyright 2016, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-90801-02

Original Effective Date: 08/15/01

Reviewed: 10/25/12

Revised: 05/11/14

Subject: Psychiatric Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Psychiatric disorders are those contractually referred to as mental and nervous for which coverage under psychiatric benefits applies. Psychiatric or mental and nervous disorders are those normally listed in the Diagnostic and Statistic Manual of Mental Disorders published and reviewed by the American Psychiatric Association.

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

A psychiatric diagnostic interview can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition.

Psychotherapy is the treatment of mental illness and behavior disturbances, in which the provider establishes a professional contact with the patient and through therapeutic communication and techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, encourage personality growth and development and facilitate coping mechanisms.

Interactive individual psychotherapy is used when the patient does not have the ability to interact by ordinary verbal communication; therefore, non-verbal communication skills are employed, or an interpreter may be necessary. Interactive procedures are distinct forms of diagnostic procedures and psychotherapeutic procedures which predominately use non-verbal communication to overcome barriers to therapeutic interaction between the provider and the patient who has lost or who has not yet developed either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the physician if he/she were to use verbal communication.

Group psychotherapy is administered in a group setting with a trained group leader in charge of several patients. The group is a carefully selected group of patients meeting for a prescribed period of time during which common issues are presented and generally relate to and evolve towards a therapeutic goal. Since it involves psychotherapy it must be led by a person, authorized by state statute to perform this service. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, and support.

Health and behavior assessment is used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus of the assessment is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.

Health and behavior intervention is used to modify the psychological, behavioral, emotional, cognitive and social factors identified as important to or directly affecting the patient’s physiological functioning, disease status, health, and well-being. The focus of the intervention is to improve the patient’s health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.

POSITION STATEMENT:

Psychiatric diagnostic interview examination, individual psychotherapy and group psychotherapy meets the definition of medical necessity when the patient has a psychiatric illness or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

Interactive individual psychotherapy meets the definition of medical necessity when the patient has a psychiatric illness or demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning for ANY of the following indications:

Family psychotherapy (psychiatric services provided to family members for the benefit of the patient) meets the definition of medical necessity when it is an integral part of the patient's treatment plan and utilizes psychotherapeutic techniques for the following indications:

Psychiatric evaluation of hospital records meets the definition of medical necessity and includes evaluation of the following:

Interpretation/explanation of results of psychiatric data to family or other responsible person (90887) meets the definition of medical necessity for all indications.

Electroconvulsive therapy (90870 – 90871) rendered by a physician meets the definition of medical necessity on an individual consideration basis. Documentation of medical necessity should include history and physical, office and progress notes that support the need for the type of therapy and the patient’s treatment record shall be reviewed and the proposed convulsive therapy agreed to by one other physician not directly involved with the patient. Such agreement shall be documented in the patient’s treatment record and shall be signed by both physicians per Florida State Statute 458.325 Electroconvulsive and psychosurgical procedures.

Hypnotherapy (90880) meets the definition of medical necessity when it is an integral part of a treatment plan for nervous or mental disorders (excluding smoking and/or dietary control).

Examples of indications for the use of hypnotherapy include:

Psychological testing (96101 – 96103) meets the definition of medical necessity when it is an integral part of a treatment plan for psychodiagnostic assessment of personality and psychopathology.

Health and behavior assessment/ intervention (96150 – 96155) meet the definition of medical necessity for all indications.

NOTE: Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions (90882) and preparation of report of patient’s psychiatric status, history, treatment or progress for other physicians, agencies or insurance carriers (90889) are NOT covered when performed as independent services.

Psychoanalysis (90845) does not meet the definition of medical necessity due to the lack of documented effectiveness as compared to the standard of practice for other forms of psychotherapy.

The following psychiatric services do not meet the definition of medical necessity when performed as independent services:

Psychiatric telephone consultation does not meet the definition of medical necessity as the success of treatment is supported by a thorough assessment of the patient, which cannot be achieved via the telephone.

Individual psychotherapy or interactive individual psychotherapy services do not meet the definition of medical necessity for the following situations:

Group psychotherapy services do not meet the definition of medical necessity for the following situations:

Based on peer-reviewed literature and case studies, individual and group psychotherapy services are successful only when the patient is able to effectively communicate, including interaction of sufficient quality, with the therapist and members of the group. The standard of care for psychotherapy services does not include the teaching of grooming skills, monitoring activities of daily living, recreational therapy or social interaction.

Transcendental meditation does not meet the definition of medical necessity, as it is not recommended as a treatment modality in the standard practice of care for psychiatric conditions.

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient) (e.g., insight oriented, behavior modifying or supportive psychotherapy) (90875, 90876) is considered experimental or investigational, as there is insufficient evidence to support the use of and permit conclusions concerning individual psychophysiological therapy incorporating biofeedback training.

BILLING/CODING INFORMATION:

The following codes may be used to describe psychiatric services:

CPT Coding:

90785

Interactive complexity (list separately in addition to the code for primary procedure)

90791

Psychiatric diagnostic evaluation

90792

Psychiatric diagnostic evaluation with medical services

90832

Psychotherapy, 30 minutes with patient and/or family member

90833

Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

90834

Psychotherapy, 45 minutes with patient and/or family member

90836

Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

90837

Psychotherapy, 60 minutes with patient and/or family member

90838

Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

90839

Psychotherapy for crisis; first 60 minutes

90840

Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)

90845

Psychoanalysis (non-covered)

90846

Family psychotherapy (without the patient present)

90847

Family psychotherapy (conjoint psychotherapy) (with patient present)

90849

Multiple-family group psychotherapy

90853

Group psychotherapy (other than of a multiple-family group)

90863

Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure)

90865

Narcosynthesis for psychiatric diagnostic and therapeutic purposes (e.g., sodium amobarbital [Amytal] interview)

90870

Electroconvulsive therapy (includes necessary monitoring)

90875

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); 30 minutes (investigational)

90876

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); approximately 45 minutes (investigational)

90880

Hypnotherapy

90882

Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions (non-covered)

90885

Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes

90887

Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient

90889

Preparation of report of patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies or insurance carriers (non-covered)

96101

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

96102

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face

96103

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMP), administered by a computer, with qualified health care professional interpretation and report

96150

Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes, face-to-face with the patient, initial assessment

96151

Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes, face-to-face with the patient, re-assessment

96152

Health and behavior intervention, each 15 minutes, face-to-face; individual

96153

Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)

96154

Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)

96155

Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present)

REIMBURSEMENT:

Reimbursement for psychiatric diagnostic interview examination (90791) is limited to four (4) examinations in a 12-month period.
Reimbursement for group psychotherapy (90853) is limited to one session per day.
Reimbursement for psychological testing (96101 – 96103) is not to exceed a maximum of eight (8) hours during a 12-month period.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: Biofeedback Therapy (30.1), Transcendental Meditation (30.5), Consultations with a Beneficiary's Family and Associates (70.1) located at cms.gov.

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Biofeedback (L29066), Family Psychotherapy (L29173), Group Psychotherapy (L29185), Health and Behavior Assessment/Intervention (L29186), Psychotherapy (L29196), Interactive Complexity Services (L29201), Psychiatric Diagnostic Evaluation (L29264), Psychiatric Diagnostic Evaluation and Psychotherapy Services (L33128) and Noncovered Services (L29288) located at fcso.com.

DEFINITIONS:

Hypnotherapy: psychotherapy that facilitates suggestion, re-education or analysis by means of hypnosis.

Psychoanalysis: learning about one’s inner mind and how the mind developed from childhood; not the same as psychotherapy. Uses investigative techniques to gain insight into a person’s unconscious motivations, conflicts, and symbols and thus to effect a change in maladaptive behavior.

Psychological testing: includes assessment of personality and other traits that may affect the way a person is able to function in daily life. Some psychological testing is done for the purpose of satisfying curiosity, for career decision-making, or for educational reasons. In other cases, psychological testing may provide clues to medical diseases or behavioral problems that show up in many aspects of living.

Transcendental meditation (TM): a skill claiming to produce a state of rest and relaxation when practiced effectively. Patients are typically taught techniques by persons trained in transcendental meditation over the course of several sessions. TM is sometimes prescribed for the treatment of mild hypertension or adjunctive therapy for essential hypertension and for other psychological stress-related disorders.

RELATED GUIDELINES:

Neuropsychological Testing, 01-95805-14

OTHER:

None applicable.

REFERENCES:

  1. AHRQ Agency for Healthcare Research and Quality. Guideline Summary NGC-3572: Practice guideline for the treatment of patients with schizophrenia. Second edition. Arlington (VA): American Psychiatric Association; 2004 Feb.
  2. AHRQ Agency for Healthcare Research and Quality. Guideline Summary NGC-4985: Practice guideline for the treatment of patients with substance use disorders. American Psychiatic Association. Am J Psychiatry 2006 Aug;163(8 Suppl):5-82.
  3. AHRQ Agency for Healthcare Research and Quality. Guideline Summary NGC-4987: Practice guideline for the treatment of patients with eating disorders. American Psychiatric Association. Am J Psychiatry 2006 Jul;163(7 Suppl):4-54. Reaffirmed 2011.
  4. AHRQ Agency for Healthcare Research and Quality. NGC007124: Practice guideline for the treatment of patients with panic disorder. American Psychiatric Association; Am J Psychiatry 1998 May;155(5 Suppl):1-34 (revised Jan. 2009).
  5. AHRQ Agency for Healthcare Research and Quality. Guideline Summary NGC-8628: Clinical practice guideline for schizophrenia and incipient psychotic disorder. Catalan Agency for Health Technology Assessment and Research; 2009 Mar.
  6. AHRQ Agency for Healthcare Research and Quality. Guideline Summary NGC-9117: Major depression in adults in primary care. Institute for Clinical Systems Improvement (ICSI); 2012 May.
  7. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Am J Psychiatry 2000 Apr; 157(4 Suppl):1-45. Revised 12/16/10. (Accessed 10/03/12)
  8. American Psychiatric Association: Practice Guideline for the Treatment of Bipolar Disorder, Second Edition. Am J Psychiatry. 1994 Dec;151(12 Suppl):1-36. Revised 12/16/10. Accessed at: http://psychiatryonline.org/content.aspx?bookid=28&sectionid=2021669
  9. American Psychiatric Association Position Statement: Psychiatry & Primary Care Integration Across the Lifespan. September 2010.
  10. American Psychiatric Association Position Statement: Access to Comprehensive Psychiatric Assessment and Integrated Treatment, September 2009.
  11. American Psychiatric Association Position Statement: Psychotherapy by Psychiatrists. September 2009.
  12. American Psychiatric Association Steering Committee on Practice Guidelines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006 Jun; 163(6 Suppl):3-36. Reaffirmed 2011. (Accessed 10/03/12)
  13. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 2.01.28 Neurofeedback 09/18/07.
  14. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 2.01.53 Biofeedback for Miscellaneous Indications August 2011.
  15. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 30.1 Biofeedback Therapy. (Accessed 09/28/11).
  16. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 30.5 Transcendental Meditation 11/11/95. (Accessed 09/28/11).
  17. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 70.1 Consultations with a Beneficiary’s Family and Associates. (Accessed 09/28/11).
  18. ClinicalTrials.gov. Integrated Treatment for Comorbid Depression and Obesity in Adolescents, NCT01128764. National Institute of Mental Health (NIMH). Verified on May 21, 2010.
  19. ClinicalTrials.gov. Depression Attention for Women Now (The DAWN Study), NCT01096316. National Institute of Mental Health (NIMH). Last Updated on July 20, 2010.
  20. Florida Medicare Part B Local Coverage Determination. L6264. Psychiatric Diagnostic Interview Examination (Retired 02/01/09).
  21. Florida Medicare Part B Local Coverage Determination. L29264. Psychiatric Diagnostic Interview Examination. 12/04/08.
  22. Florida Medicare Part B Local Coverage Determination. L24032. Interactive Psychiatric Services. 02/28/07 (Retired 02/01/09).
  23. Florida Medicare Part B Local Coverage Determination. L29201. Interactive Psychiatric Services. 10/01/11. (Accessed 10/03/12)
  24. Florida Medicare Part B Local Coverage Determination. L29264. Psychiatric Diagnostic Interview Examination. 02/02/09. (Accessed 10/03/12)
  25. Florida Medicare Part B Local Coverage Determination. L5620. Individual Psychotherapy. 04/11/06 (Retired 02/01/09).
  26. Florida Medicare Part B Local Coverage Determination. L22125. Family Psychotherapy. 08/07/06 (Retired 02/01/09).
  27. Florida Medicare Part B Local Coverage Determination. L29173. Family Psychotherapy. 10/01/11.
  28. Florida Medicare Part B Local Coverage Determination. L22468. Group Psychotherapy. 04/11/06 (Retired 02/01/09).
  29. Florida Medicare Part B Local Coverage Determination. L29185. Group Psychotherapy. 10/01/11. (Accessed 10/03/12)
  30. Florida Medicare Part B Local Coverage Determination. L5793. Biofeedback. 10/01/05 (Retired 02/01/09).
  31. Florida Medicare Part B Local Coverage Determination. L29066. Biofeedback. 10/01/10.
  32. Florida Medicare Part B Local Coverage Determination. L22471. Health and Behavior Assessment/Intervention. 04/11/06 (Retired 02/01/09).
  33. Florida Medicare Part B Local Coverage Determination. L29186. Health and Behavior Assessment/Intervention. 02/02/09. (Accessed 10/03/12)
  34. Florida Medicare Part B Local Coverage Determination. L29288. Noncovered Services. 10/16/11.
  35. Florida Medicare Part B Local Coverage Determination. L29196. Individual Psychotherapy. 10/01/11. (Accessed 10/03/12)
  36. Florida Medicare Part B Local Coverage Determination (First Coast Service Options). L33128. Psychiatric Diagnostic Evaluation and Psychotherapy Services. 06/04/13. Accessed 07/25/13.
  37. Florida Statute 458.325. Electroconvulsive and psychosurgical procedures, effective 2002. (Accessed 10/03/12)
  38. Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH, Van Rhoads RS. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. American Psychiatric Association, October 2010.
  39. Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M. Meditation therapy for anxiety disorders, Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004998. DOI: 10.1002/14651858.CD004998.pub2.
  40. Wilkes TC, Guyn L, Li B, Lu M, Cawthorpe D. Association of Child and Adolescent Psychiatric Disorders with Somatic or Biomedical Diagnoses: Do Population-Based Utilization Study Results Support the Adverse Childhood Experiences Study? Perm J. 2012 Spring;16(2):23-6.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/25/12.

GUIDELINE UPDATE INFORMATION:

08/15/01

Medical Coverage Guideline revised and reformatted.

01/01/02

Revision to guideline consisting of addition of Health and behavior assessment/ intervention codes.

08/15/02

Revision to guideline consisting of removal of unrelated CPT codes.

01/01/03

Review and revision of guideline consisting of 2003 HCPCS update.

02/15/04

Review and revision of guideline consisting of updated references and removal of insulin shock therapy.

03/15/05

Review and revision of guideline consisting of updated references, revision of description section, and removal of CPT codes 90816 – 90829.

01/01/06

Annual HCPCS coding update consisting of the deletion of 96100 and 90871, revision of 90870, and the addition of 96101 – 96103.

02/15/06

Review and revision of guideline consisting of updated references.

02/15/07

Review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline; references updated.

01/01/08

HCPCS coding update consisting of the revision of 96101.

02/15/08

Review and revision of guideline consisting of updated references.

04/01/09

Scheduled review; no change in position statement. Update references and revise reimbursement statement with removal of reference to CPT code 90887. Additional reimbursement information deleted.

04/15/09

Scheduled review; no change in position statement. Update references and revise reimbursement statement. Additional reimbursement information deleted.

06/29/09

Update reimbursement for psychiatric diagnostic interview examination (90801) is limited to four (4) examinations in a 12-month period.

10/15/09

Scheduled review; no change in position statement.

11/15/10

Revision; exception for Medicare Advantage Products updated to reflect ICD-9 codes that support medical necessity for psychiatric services.

10/01/11

Revision; updated code descriptors for ICD9 codes 317, 318.0, 318.1 and 318.2.

11/15/11

Scheduled review; no change in position statement. Updated description section, Medicare program exception and references.

11/15/12

Scheduled review. Position statement maintained. Revised description, Medicare Advantage ICD9 coding section and definitions. Updated references.

01/01/13

Annual CPT coding update. Added 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840 and 90863. Revised code descriptors for 90875, 90876 and 90889. Deleted 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90857 and 90862.

08/15/13

Revision; Program Exceptions section and references updated.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: August 26, 2016: 07:52 AM