Mental Health

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

"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)
  • 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

CPT Code Description
G0444 Annual depression screening; up to 15 mins (11 months elapsed between screenings)

 

  • 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

CPT Code Description
G0442 Annual alcohol misuse screening; up to 15 minutes (at least 8 minutes)
G0443 Face-to-face behavioral counseling for alcohol misuse, 15 minutes

 

  • 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), 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)

Psychiatric Diagnostic Evaluation (PDE)

CPT Code Description
90791 PDE without medical services
90792 PDE with medical services; add medical assessment

 

  • 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)
  • Place of Service (POS) = Office (11) or Outpatient (19/22)
  • CPT 90792 adds medical assessment or physical exam piece

Psychotherapy and Evaluation and Management (E/M)

CPT Code Description
90832 Psychotherapy, 30 minutes with patient
90833 Psychotherapy with E/M, 30 minutes with patient
90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy with E/M, 45 minutes with patient
90837 Psychotherapy, 60 minutes with patient
90838 Psychotherapy with E/M, 60 minutes with patient

 

  • 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 1995 or 1997 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 / Neuropsychological Testing

CPT Code Description
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
96112 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory, and/or executive functions by standardized developmental instruments when performed), by physician or other QHP, with interpretation and report; first hour
+96113 Each additional 30 minutes (List separately in addition to code for primary procedure)
96125 Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of QHP time, both face-to-face (F2F) time administering tests to the patient and time interpreting these test results and preparing the report
96127 Brief screening for emotional/behavioral assessment (e.g., depression, anxiety, attention-deficit or hyperactivity disorder [ADHD], eating disorders, etc.), with scoring and documentation, per a standardized instrument), like the Patient Health Questionnaire (PHQ-9), General Anxiety Disorder scale (GAD-7) and Depression Anxiety Stress Scales-with 4point Likert-type scale (DASS-21). The assessment must be provided and scored by trained administrative staff.
96130 Psychological testing evaluation services by physician or other QHP, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
+96131 Each additional hour (List separately in addition to code for primary procedure)
96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
+96133 Each additional hour (List separately in addition to code for primary procedure)
96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
+96137 Each additional 30 minutes (List separately in addition to code for primary procedure)
96138 Psychological/r neuropsychological test administration and scoring by technician, two/more tests, any method; first 30 mins
+96139 Each additional 30 minutes (List separately in addition to code for primary procedure)
96146 Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only

 

  • 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

CPT Code Description
96116 Neurobehavioral status; first hour
+96121 Each additional hour

 

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

CPT Code Description
90839 Psychotherapy for crisis; first 60 minutes
+90840 Each additional 30 minutes

 

  • 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

CPT Code Description
90853 Interpersonal interactions, support, etc., with several patients; typically, 45-60 mins.

 

  • 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

CPT Code Description
90846 Family psychotherapy without patient present; 50 minutes - no less than 26 minutes (midpoint)
90847 Family psychotherapy, conjoint with patient present; 50 minutes
90849 Multiple-family group psychotherapy by physician directed to effects of patient's condition on the family and generally not covered and denies; must appeal

 

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

CPT Code Description
+90785 Interactive complexity (list separately in addition to primary procedure)

 

  • 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
CPT Code Description
90845 Psychoanalysis

 

  • 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
CPT Code Description
90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes

 

  • 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

CPT Code Description
90867 Initial including cortical mapping, motor threshold determination, delivery and management
90868 Subsequent with delivery and management; per session
90869 Subsequent redetermination with delivery and management

 

CPT Code Description
90880 Hypnotherapy

 

  • 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 96150-96154); report the major service performed. Do not report these codes in conjunction on the same date as per CCI edits.

HBAI Coverage, Billing and Documentation

  • Only Clinical Psychologist (CP-spec 68) may provide initial services
  • Physician, CNS, NP or PA bill E/M or preventive codes
  • POS includes office or facility setting
  • HBAI never provided/billed "incident to" by
    • Licensed Clinical Social Worker (LCSW), Physical or Occupational Therapist (PT or OT), Counselors (any), 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
CPT Code Description
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)

 

Documentation for HBAI psychological evaluation/intervention and to successfully manage his/her physical illness

  • CPT 96150: Initial assessment includes all
    • Date of initial diagnosis of physical illness
    • Clear rationale why assessment required/performed
    • Assessment outcome (mental status)-ability to understand
    • Goals/expected duration of specific psychological intervention(s)
  • CPT 96151: Re-assessment, detailed progress notes include all
    • Date of change in mental or physical status
    • Sufficient rationale for why re-assessment required
    • Clear indication of events that necessitate re-assessment
  • CPT 96152 - 96154: Intervention service includes
    • Evidence that patient has capacity to understand and respond
    • Clearly defined psychological intervention planned
    • Goals of psychological intervention
    • Improve compliance with medical treatment plan/response
    • Rationale for frequency and duration of services

Although valuable to care, not medically necessary psychological interventions:

  • Documentation does not indicate biopsychosocial factor affecting treatment
  • Patient has no capacity to understand/respond during F2F (e.g., impaired mental status)
  • Disorientation to time, place and/or person
  • Cannot recall location of own room or faces
  • Inability to recall that he/she is in a nursing home or SNF
  • Does not require psychological support to successfully manage his/her physical illness

Behavioral Health Integration (BHI)

CPT Code Description
99483 Comprehensive assessment/care planning for patients with cognitive impairment); 20 mins.
99484 General BHI care management for behavioral health conditions, at least 20 minutes of clinical staff time; directed by a physician or other qualified health care professional time, per calendar month

 

  • 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)

CPT Code Description
99492 Initial psychiatric collaborative monthly management; first 70 mins
99493 Subsequent psychiatric collaborative management; first 60 mins
+99494 Initial/subsequent psychiatric collaborative care management; each additional 30 mins

 

  • 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

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

 

Last Updated Dec 09, 2019

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.