Psychiatry and Psychology are specialised fields for the diagnosis and treatment of various mental health disorders and/or diseases. References to providers include physicians and nonphysicians, such as clinical psychologists, independent psychologists, nurse practitioners, clinical nurse specialists and physician assistants when the services performed are within the scope of their state licence and clinical practice/education. Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. Psychiatric service CPT codes should not be used when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes are more appropriate.
Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. These CPT codes should not be used as generic psychiatric service CPT codes when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.
Family psychotherapy services are covered only where the primary purpose of such Psychotherapy is the treatment of the patient’s condition. Examples include:
CPT code 90849 represents multiple-family group psychotherapy and would generally be non covered by Medicare. Such group therapy is directed to the effects of the patient’s condition on the family, and does not meet Medicare’s standards of being part of the provider's personal services to the patient. Claims for 90849 may be approved on an individual consideration basis. CMS Publication 100-03; Medicare National Coverage Determinations Manual, Chapter 1, § 70.1 Psychiatric services must be performed by a qualified healthcare provider. See PSYCH-013 for incident to psychiatric services guidelines.
An E/M service may be substituted for the initial interview procedure, including consultation CPT codes, (CPT codes 99241-99263), provided required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. E/M CPT codes do not include a psychotherapy service.
CPT codes 90802, 90810-90815, 90823-90829 and 90857 may also be covered for any psychiatric disorder as specified in the “ICD-9-CM codes that Support Medical Necessity” section for adults who also have one of the conditions as specified in the Local Coverage Determination. Both the primary psychiatric diagnosis and secondary communication disorder must be submitted on the claim.
These CPT codes represent insight-oriented, behaviour-modifying, supportive, and/or interactive psychotherapy. Of these, CPT codes 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, and 90829 include medical evaluation and management (E/M) services including continuing medical diagnostic evaluation as well as pharmacological management. Therefore, the same healthcare provider may not bill pharmacological management (90862) and E/M service CPT codes separately on the same day as a psychotherapy service.
CPT codes 90846 and 90847 represent psychotherapy services for the treatment of mental disorders. They should not be used when the service performed is taking a family history or E/M counselling services. E/M counselling services should be coded with the appropriate E/M CPT code according to the time involved. Family counselling does not include the supervision of or therapy with professional caretakers or staff.
The guidelines in the “Documentation” section under CPT codes 90804 through 90829 (psychotherapy) apply to CPT code 90853 - group psychotherapy. It is recommended that the time of the therapy also be documented. To establish medical necessity of the service, claims must be submitted with a covered diagnosis.
CPT code 90862 is intended to refer to a visit that is focused on the monitoring and prescribing of psychopharmacologic agents. Relevant history is obtained, a mental status examination is performed, and medical decision making (i.e., assessment of treatment response and ongoing treatment formulation) occurs during such a visit providing all of the elements are documented. Psychopharmacologic agents may be initiated or adjusted during such a visit.
CPT codes 90875 and 90876 are described as individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with patient), with psychotherapy (e.g., insight oriented, behaviour modifying or supportive psychotherapy).
Medicare does not cover biofeedback for the treatment of psychosomatic disorders.
CPT codes 90810-90815 and 90823-90829 should not be billed on the same dates of service as CPT codes 90804-90809 or 90816-90822.
CPT code 90857 should not be billed on the same date of service as 90853. CPT code 90857 should also not be billed more than once per day for the same beneficiary unless he/she has participated in a separate and distinct group therapy session.
In the infrequent event that a patient has a separate and distinct individual psychotherapy and group therapy session in one day, modifier -59 should be appended to the CPT code for the second session.