Mental Health - JE Part B

Psychiatry and Psychotherapy Services

Medicare covers annual depression screening for adults in the primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up.

Medicare Part B covers medically necessary outpatient mental health benefits for psychiatric services for the diagnosis and treatment including:

• Sign(s), symptom(s) or patient complaint necessitating service
• Ongoing assessment and family member involvement
• Possible intervention of psychotherapeutic adjustments
• Depression and Alcohol Misuse Screenings
• Psychiatric Diagnostic Evaluations
• Psychotherapy (Individual and Group)
• Crisis Psychotherapy
• Psychoanalysis
• Psychological Testing
• Miscellaneous Mental Health benefits
• Health and Behavior Assessment and Intervention (HBAI)
• Behavioral Health Integration (BHI) and Collaborative Care Model (CoCM)

View below related information on this webpage.

• Mental Health Providers
• Billing, Coding, and Coverage
• Behavior Health
• Psychotherapy Documentation
• Miscellaneous Information
• Resources

Mental Health Providers

• Psychiatrist/Physician
  • PhD, PsyD, MD, and DO
• Psychologist
  • Clinical Psychologist (CP), Independent Psychologist (IPP) and Doctor of Psychology (PsyD, PhD)
• Nonphysician Practitioner (NPP) or mid-level providers may work "incident to" or bill independently
  • Certified Nurse Midwife (CNM)
  • Certified Registered Nurse Anesthetists (CRNA) - Supervision of diagnostic psychological and neuropsychological tests
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Clinical Nurse Specialist (CNS)
  • Licensed Clinical Social Worker (LCSW)
  • Marriage and Family Therapist (MFT) or Mental Health Counselors (MHC)

"Incident To" Practitioners or Auxiliary Personnel

• Cannot enroll or bill direct to Medicare - may treat with psychiatric counseling only under "incident to"

• Qualified Mental Health Professional (QMHP/QMP)
• Registered/Licensed Professional Nurse (RN/LPN)
• Counselors include Licensed Medical Health or Professional (LMHC/LPC), Certified (CMHC), Chemical Dependency Professional (CDP)
• Licensed Marriage and Family Therapist (LMFT) or Marriage and Family Counselors (MFC) - not qualified to submit Medicare claims

• Never covered for pastoral or marriage counseling

Only those specialties listed on the Eligible Specialties webpage are eligible to enroll in the Medicare program.

Keep your Medicare enrollment current though preferred websites for the online Provider Enrollment Chain and Ownership System (PECOS) and National Provider Identifier (NPI) at National Plan and Provider Enumeration System NPI Registry (NPPES)

Billing, Coding, and Coverage

Depression Screening

• Includes patient form completion, recording by medical assistant and physician discussion with patient
• Coinsurance and deductible waived
• Furnished by Psychiatrist or Psychologist only with clinical staff-assisted depression care supports in place
• Primary care settings only:
  • 11 (Office), 19 or 22 (Outpatient hospital) or 71 (State or local public health clinic)
• Not covered same day as initial AWV/IPPE; however, may add to subsequent AWV
• Not separately reimbursable: Self-help materials, telephone or web-based counseling
• See also National Coverage Determination (NCD) 210.9

Alcohol Screening and Behavioral Counseling

• Competent women older than 65 (seven drinks or more per week or three drinks per occasion)
• Competent men 65 years and younger (greater than 14 drinks per week or more than four drinks per occasion)
• If screening (HCPCS G0442) positive, then up to four brief face-to-face (F2F) counseling sessions (HCPCS G0443)
• Must have at least three (3) of the following dependence
  • Withdrawal symptoms, impaired control, tolerance, acquisition preoccupation, unsuccessful efforts to quit, continue use despite consequences, can sustain social, occupational or recreational)
• Coinsurance and deductible waived
• Primary care settings only
  • 11 (Office), 12 (Home), 19 or 22 (Outpatient hospital) or 71 (State or local public health clinic)
• Not covered same day as initial AWV/IPPE; however, may add to subsequent AWV
• No specific diagnosis and Five A approach (assess, advise, agree, assist and arrange)
• See also CMS Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse National Coverage Determination (NCD) (210.8)

Cognitive Assessment and Care Plan (CACP)

• CMS Cognitive Assessment & Care Plan Services
• Medicare Coverage and Payment of Cognitive Assessment & Care Plan Services
• Cognitive Assessment and Care Plan (CACP)

Psychiatric Diagnostic Evaluation (PDE)

• Chief complaint, biopsychosocial assessment (includes history, mental status), initial treatment plan, lab/diagnostic test result, medication, initial diagnosis)
• Time log documentation (intervention, strategies)
• Report once per day and may report more than once/year (with separate evaluation)
• Never used "incident to" or same day as Evaluation and Management (E/M)
• CPT 90792 adds medical assessment or physical exam piece

Psychotherapy and Evaluation and Management (E&M)

• Focus on the patient and patient presence required for all/majority of this time-based service
• To report psychotherapy and E/M same day, both must be significant and separately identifiable
  • Must meet E/M key components such as history, examination and medical decision-making per CPT manual and 2021 E/M guidelines
• Covered POS include: office (11), inpatient (21) and outpatient (22)
• In general, providers select code that matches as close to actual time spent performing psychotherapy
• Clearly document actual time spent
• CPT provides flexibility by identifying time ranges that may be associated with codes
• CPT 90832 (or + 90833): 16 to 37 minutes,
• CPT 90834 (or + 90836): 38 to 52 minutes, or
• CPT 90837 (or + 90838): 53 minutes or longer
• Do not bill psychotherapy codes for sessions lasting less than 16 minutes

Psychological or Neuropsychological Testing

• For Psychological, or Neuropsychological testing that spans more than one day, you will use the last day of service with a quantity of 1
• 2019 codes above replaced deleted CPTs 96101, 96102, 96103, 96118, 96119 and 96120
• Administered by MD/other Qualified Health Professional (QHP), Technician or Computer
• Medical records need specific tests performed, mental illness symptoms, number of hours testing, test results interpretation, report time-based, psychological testing evaluation, administration and scoring services

Neurobehavioral Status Exam

Face-to-Face (F2F) with patient includes:

• Assess patient's attention, language, memory, planning and problem-solving by using pre, intra and post service work by physician or qualified health plan (QHP)
• Interpreting test results and preparing report
• Must pass mid-point total time to bill (Hour = at least 31 minutes) (30 minutes = at least 16 minutes)

Crisis Psychotherapy

• Presenting problem life-threatening to patient or others and complexity requires immediate attention to a patient in high distress
• Requires urgent assessment, restore safety, resource mobilization to defuse crisis, implement interventions to minimize psychiatric trauma potential
• Cannot bill in addition to other psychotherapy codes; only billed once/day

Group Psychotherapy

• Groups designed to target specific problem; depression, obesity, panic disorder, social anxiety (anger, shyness, loneliness, low self-esteem), loss of family member, chronic pain or substance abuse
• Does not include recreational activities, play, eating together, art or music therapy, excursions, sensory stimulation, socialization, motion therapy, etc.
• Led by Psychiatrist or psychologist
• If led by QMP/QHP, must have a follow up visit with psychiatrist (psychiatric aides not eligible)
• Sessions not to exceed 10 participants

Family Psychotherapy - Restricted Codes

• Family counseling services covered only where primary purpose is treatment of patient's condition
• Consultations with Beneficiary's Family - CMS Internet Only Manual (IOM), Publication 100-03, Chapter 1, Part 1, Section 70.1

Services Never Covered

• Grooming skills/recreation/excursions/entertainment
• Environmental intervention (CPT 90882)
• Geriatric day care programs
• Report preparation
• Explanation of results/data
• Meals and transportation
• Marriage/pastoral counseling
• Monitoring activities of daily living (ADL)
• Phone calls or travel time
• Psychosocial programs when recreation activities involved
• Vocational training for employment opportunities, work skills or work settings
• Certain severe cognitive psychotherapy diagnoses for severe and profound advanced mental stages, dementia or Alzheimers - ICD-10 F72, F73 and F79
• Self-help materials or web-based counseling
• Language translators or interpreters

Bundled CPTs or Medicare Status B - cannot charge beneficiary or Medicare

• CPT 90863 - Pharmacologic management-bill appropriate E/M or drug/administration codes
• CPT 90885 - Evaluation of hospital records, reports, tests
• CPT 90887 - Explanations to family, employers, etc.
• CPT 90889 - Report preparation for courts, agencies, etc.
• CPT 96040 - Medical genetics and genetic counseling with patient/family

Check multiple codes billed same day for bundling with the CMS National Correct Coding Initiative (NCCI).

Other Mental Health CPT Codes

• Complexity may involve third party; such as child welfare, probation or parole officer
  • Another family member must step in for other family members bickering
• May bill in addition to CPTs 90791, 90792, 90832-90834, 90837, 90838 and 90853

• Investigative techniques to gain insight into unconscious conflicts and motivations
• Do not confuse with psychotherapy
• Not time related, billed only once daily
• CNS and/or NP not eligible for payment

• Restricted to Physicians only (MD)
• Used for sedative/tranquilizer drug administration (usually IV)
• Relax patient and remove inhibitions for discussion in fully conscious state
• Document medical necessity (e.g., patient had difficulty verbalizing about psychiatric problems without drug aid)
  • Record specific pharmacological agent, dosage administered and if technique effective or non-effective

Repetitive Transcranial Magnetic Stimulation (rTMS) for Severe Depression

• Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder Local Coverage Determination (LCD)
• Priced under contractor priced (C Status) fee schedule

• Medicare may consider if treatment during stand-alone session and meets reasonable/necessary from a medical or psychological condition
• Not covered
  • Psychosomatic conditions
  • Ordinary muscle tension condition
  • Weight loss not covered for Medicare
• Cannot bill with psychotherapy on same date of service (DOS)

Behavioral Health

Health Behavior Assessment and Intervention (HBAI)

In Medicare, the objective of HBAI is to assist patients to overcome their perceived emotional and social barriers to their physical disease management and self-management of chronic disease. The codes address a wide range of physical health issues; such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors and overall adjustment to physical illness. In almost all these cases, a physician will have previously diagnosed the patient's physical health problem.

Unlike some other codes, there are no special additional accreditation requirements to provide HBAI services. For patients that require both psychiatric services in the CPTs 90832-90899 range, as well as HBAI (CPTs 96156-96168); report the major, predominant service performed. Do not report these codes in conjunction on the same date as per Correct Coding Initiative (CCI) edits.

HBAI Coverage, Billing and Documentation

• Clinical Psychologist (CP-spec 68) may provide initial services
• Licensed Clinical Social Workers (LCSW), Marriage and Family Therapists (MFT) and Mental Health Counselors (MHCs) can provide HBAI services for the following codes: 96156, 96158-96159, 96164-96165, and 96167-96168.
• Physician, CNS, NP or PA bill E/M or preventive codes
• POS includes office or facility setting
• HBAI never provided/billed "incident to" by
  • Physical or Occupational Therapist (PT or OT), Qualified Mental Health Professionals (QMHP), etc.
• Code of Federal Regulation (CFR) Title 42, Part 410.73(b)(1) SSA 1861(hh)(2)
  • State Scope of License may allow; however, services limited to diagnosis and treatment of mental illness
  • HBAI focus not mental health (instead physical problems (cancer/congestive heart failure)
  • Other specialties or auxiliary staff unable to treat; even "incident to"

Not covered:

• CPT 96155 (family without patient present)
• CPT 90901 (biofeedback) as HBAI
• Claims with mental health diagnoses, psychosomatic conditions or psychiatric disorders
• Any group or individual social activities
• Teaching patient simple self-care or social interaction skills
• Any advice (e.g. religious or work related)
• Tobacco or caffeine withdrawal support; if only reason
• Weight loss management

All must be met for Medicare coverage:

• Patient has underlying physical illness or injury
• Indications that biopsychosocial factors significantly affect treatment/medical management
• Patient alert, oriented and capacity to understand
• Respond meaningfully during F2F encounter
• If patient has mental health diagnosis, no HBAI

The following CPTs have the same requirements:

• Event-based for patients that require psychiatric services, adaptive behavior services or health behavior assessment or intervention; report the predominant service performed
• Document clear rationale why performed with outcome, frequency and duration goals, and patient’s compliance with medical treatment plan
• Not reported same day as psychiatric services (90785-90899) or adaptive behavior services (97151-97158)
• Not reported same day as evaluation and management (E/M) services
• CPTs 96156, 96158, 96164 and 96167 not reported for less than 16 minutes
• Add on CPTs 96159, 96165 and 96168 not reported for less than 8 minutes
• CPT 96156 replaces 96150 and 96151
  • Once per day
  • Includes date of initial diagnosis of physical illness, clear rationale why assessment required/performed, assessment outcome (mental status), goals and expected duration of specific psychological intervention(s)
• CPTs 96158/96159 replaces 96152
• CPTs 96164/96165 replaces 96153
• CPTs 96167/96158 replaces 96154
  • Patient MUST be present; if not, cannot bill Medicare

Behavioral Health Integration (BHI)

**General BHI codes (99484, G0323), must provide at least 20 minutes of care per calendar month to bill

Behavioral Health Integration Services

• Must be presenting mental, psychiatric or behavioral health condition(s) that warrant BHI services
• Diagnosis(es) could be either pre-existing or by the billing practitioner
• Behavioral health care manager able to provide face-to-face and continuous, collaborative relationship
  • Initial assessment or follow-up monitoring; including use of applicable validated rating scales;
  • Behavioral care planning, revision for patients not progressing or status changes;
  • Facilitating and coordinating treatment such as psychotherapy;
  • Pharmacotherapy, counseling and/or psychiatric consultation; and
  • Continuity of care with a designated member of the care team (at least 15 mins.)
• Similar to Chronic Care Management (CCM), except behavioral health, instead of physical chronic conditions
• Telehealth covered for both BHI and CoCM below

Collaborative Care Model (CoCM)

• Prior beneficiary permission needed (like other Chronic Care models) to inform of cost-sharing
• Billed monthly by primary care (employs behavioral health care manager) with financial to reimburse psychiatrist
• POS 11, 19 or 22 (office or outpatient hospital)
• Care planning team provides psychotherapy, pharmacology and brief interventions using evidence-based techniques with treatment strategies (e.g., behavioral activation, motivational interviewing & other focused treatment strategies)
• Track patient in registry with no special technology or format
• Cannot bill CoCM and BHI same month for same beneficiary
• Threshold time met when 50% time, plus one minute passed
  • For CoCM codes (99492-99494, G2214), unit of time obtained when mid-point passed
  • E.g., 30 minutes obtained when 16 minutes elapsed; 60 minutes obtained when 31 minutes elapsed; 70 minutes obtained when 36 minutes elapsed.

Psychotherapy Documentation

• Beneficiary name, date of service, session length
• Encounter reason - mental status
• Relevant interval history
• Service type (individual, group, family, interactive, etc.) and pertinent themes discussed
• Type of therapy or interventions used
• Patient assessment (progression/regression)
• Treatment plan/diagnosis/medication change
• Expected treatment outcomes on periodic basis
• Indicate specific symptoms, patient complaint, etc., per Social Security Act (SSA) Section 1862(a)(1)(A)
• High risk factors (suicidal ideation (S/I) and homicidal ideation (H/I); if applicable
• Modalities/frequency of treatment furnished
• Clinical note for each encounter
• Signature (name/credentials) legibly signed
• CMS/Noridian do not have sample templates; professional associations may
  • Each provider must develop their own
• Recurrent depression may include prior treatment history, diagnosis F33.0-F33.9, etc.
• E/M time separate from psychotherapy time
• Do not overlap psychotherapy and E/M services
• E/M and Psychotherapy may be on same report; specifically, separately identifiable within note
• Time indicated in psychotherapy code
• Note: Provider clearly documents in the patient's medical record, time spent providing psychotherapy service; rather than entering one total time period (that includes E/M service)

Comprehensive Error Rate Testing (CERT) Review Errors and Compliance Risk Areas

• Each distinct service (psychiatric, E/M, psychotherapy, etc.) must be separately identifiable
• Important to clearly document time spent providing psychotherapy service vs. E/M
• Mental Health CERT errors
  • Not clearly documenting
  • Time spent only on psychotherapy services
  • E/M separated (hx, exam, medical decision)
  • Missing treatment modalities
  • No progress or updated treatment plan
  • Wrong level of service selected
  • Billing codes inappropriately
  • Cannot bill less than 16 minutes

Miscellaneous Information

• No Noridian "Mental Health" LCD
• HCPCS G0176 (art, dance or music therapy) or HCPCS G0177 (substance abuse training and education) not covered

Incarcerated, In Custody or Unlawfully Present in the US - Medicare does not allow

• Claims submitted for services provided to beneficiaries in custody (or incarcerated) or unlawfully present in the US would not be eligible
• State or Local law require those individuals or groups to repay medical services received while in custody
• Social Security Administration (SSA) maintains incarceration dates
• State Department of Corrections responsible for provider payments
  • If exception and billing Medicare, append QJ modifier to CPT codes
• Beneficiaries in custody or incarcerated, not only include those under arrest or imprisoned:
  • Anyone confined completely or partially under a penal statute or rule; like home detention
  • Escaped from confinement
  • Medical furlough and/or under supervised release
• Beneficiaries required to reside in mental health facilities, halfway houses or under home detention

Resources

• CMS IOM Publication 100-04 Medicare Benefit Policy Manual Chapter 15 Sections 60 and 80.2
• CMS IOM Publication 100-04 Medicare Claims Processing Manual Chapter 15 Sections 150 - 170
• CMS IOM, Publication 100-08, Chapter 15, Section 15.4.4.13
• CMS Change Request (CR)7307 - Outpatient Mental Health Treatment Limitation - Clarification to CR 6686
• CMS CR7637 - Screening for Depression in Adults
• CMS CR7633 - Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse
• OIG - Medicare Part B Payments for Mental Health Services
• CMS Behavioral Health Integration Services_May 2023_MLN909432