Download Psychiatric and Psychological Outpatient Services

MEDICARE
COVERAGE
SUMMARY
OPTUM™
By United Behavioral Health
Psychiatric and Psychological Outpatient
Services
Guideline Number: BHCDG032015
Product:
Effective Date: August, 2015
Medicare
Revised Date:
Centers for Medicare and Medicaid Local
Coverage Determinations:
Table of Contents:
Instructions for Use
1
Key Points
2
Part I: Benefits, Limitations & Exclusions
3
Part II: Coverage Criteria
7
Part III: Best Practice & Documentation
12
Definitions
14
References
15
Coding
16
History
17
Active Outpatient Local Coverage
Determinations (as 8/12/15)
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting behavioral health
benefit plans that are managed by Optum for Medicare Advantage enrollees.
The enrollee’s specific Evidence of Coverage (EOC)/Summary of Benefits (SB) must be
referenced for specific plan provisions for coverage, limitations, and exclusions. In the event of a
conflict between these guidelines and the enrollee’s EOC/SB, the enrollee’s specific EOC/SB will
supersede these guidelines.
All reviewers must first identify enrollee eligibility, any federal or State regulatory requirements,
and the enrollee’s EOC/SB plan prior to use of this guideline.
The information provided is intended only as a guideline and will not address every aspect or
clinical situation.
In the event that there is no available guideline for a particular State, jurisdiction, condition or
service, the Optum Level of Care Guidelines should be used for medical necessity decisions
along with the enrollee’s applicable EOC/SB.
Optum reserves the right, in its sole discretion, to modify its clinical guidelines as necessary, and
to update this coverage determination guideline in accordance with updates to CMS National and
Local Coverage Determinations. While this Coverage Determination Guideline does reflect
Optum’s understanding of current best practices in care, it does not constitute medical advice.
Outpatient Services
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Coverage Determination Guideline
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Optum is a brand used by United Behavioral Health and its affiliates.
Key Points

This guideline is based on the Centers for Medicare and Medicaid Services (CMS) Local and
National Coverage Determinations (LCDs/NCDs) active at the time this guideline was written.
The intent of this document is to summarize the coverage criteria and best practices for the
delivery of outpatient services as they apply to Medicare members.

Behavioral Health care services or supplies should be provided when needed to prevent,
diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet
accepted standards of medicine (Medicare.gov, Glossary, 2015).

Benefits are available for covered services that are not otherwise limited or excluded. The
benefit information in this document is based on active CMS LCDs that may vary by State or
jurisdiction and may be updated with new or more current information since the time this
document was written.

In the event that there is no available CMS NCD/LCD for a particular State, jurisdiction,
condition or service applicable to a Medicare plan, the Optum Level of Care Guidelines
should be used for medical necessity decisions along with the member’s specific Evidence of
Coverage (EOC) or Summary of Benefits (SB).

The following grid describes Medicare covered outpatient psychiatry and psychology services
according to the member’s State or jurisdiction. In the event the member’s State/jurisdiction
does not appear on the grid, the Optum Level of Care Guidelines along with the member’s
EOC/SB should be applied.
State
Service
AL, AK, AZ, AR, CT, FL, GA, ID, IL, IN, IA,
KS, KY, LA, ME, MA, MI, MN, MS, MO, MT,
NC, ND, NE, NH, NJ, NY, OH, OR, RI, SC,
SD, TN, UT, VT, VA, VI, WA, WV, WI,
WY
Psychiatry & Psychology Services
AR, CO, DE, DC, FL, LA, MD, MI, NM, NJ,
OK, PA, PR, TX, VI
Psychiatric Diagnostic Evaluation &
Psychotherapy Services/Therapeutic
Procedure Codes

These services refer to psychiatry,
psychology, clinical social work, and
psychiatric nursing services rendered in
a hospital outpatient facility or by
individual providers for the diagnosis
and treatment of various mental
disorders or diseases.

Evaluation services include an
integrated biopsychosocial assessment
(i.e., complete medical/psychiatric
history, mental status exam,
establishment of a tentative diagnosis,
and an assessment of the patient's
ability and willingness to participate in
the proposed treatment plan).

Psychotherapy services include
individual, group, crisis oriented, and
family psychotherapy, psychoanalysis,
interactive complexity services and
Outpatient Services
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pharmacologic medication management.

IL, IN, IA, KS, KY, MI, MN, MO, NE, WI
Procedure/code descriptions for services
delivered within the scope of education,
training, and State licensure.
Psychological Services Under the
Incident to Provision

Refer to psychological services provided
“Incident to” a psychiatrist’s services
furnished as an integral, although
incidental part of the psychiatric services
provided in the course of diagnosis or
treatment. The “incident to” services
may apply to psychological services
provided by non-physicians including
clinical psychologists, clinical social
workers, nurse practitioners and clinical
nurse specialists.
PART I: BENEFITS
Before using this guideline, please check enrollee’s specific Evidence of
Coverage (EOC)/Summary of Benefits (SB) and any federal or state mandates, if
applicable.
Benefits
Benefits include the following services:

Diagnostic evaluation and assessment

Treatment planning

Referral services

Medication management

Psychotherapy

Crisis intervention
Behavioral Health care services or supplies are provided when needed to
prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms
and that meet accepted standards of medicine (CMS Benefit Policy Manual,
Section 20).
Limitations and Exclusions
Outpatient Services
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Coverage Determination Guideline
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The requested service or procedure for the treatment of a mental health condition
must be reviewed against the language in the enrollee's Evidence of
Coverage/Summary of Benefits. When the requested service or procedure is
limited or excluded from the enrollee’s EOC, or is otherwise defined differently, it
is the terms of the enrollee’s EOC/SB that prevails.
Additional Information
The lack of a specific exclusion for coverage for a service does not imply that the
service is covered.
No payment can be made for certain items and services, when the following
conditions exist (CMS Benefit Policy Manual, 2013):

Not reasonable and necessary: Items and services which are not
reasonable and necessary for the diagnosis or treatment of illness or
injury or to improve functioning are not covered.

Custodial care: Personal care that does not require the continuing
attention of trained medical or paramedical personnel. In determining
whether a person is receiving custodial care, the intermediary or carrier
considers the level of care and medical supervision required and
furnished. It does not base the decision on diagnosis, type of condition,
degree of functional limitation, or rehabilitation potential.

Excluded Investigational Devices or Procedures: These items and
procedures include any procedure, study, test, drug, equipment or
facility still undergoing study and which is generally not accepted as
standard therapy in the medical community where alternative therapy
exists.
The following are examples of outpatient services that are limited or excluded.
Please note these exclusions may vary by State/region as indicated. The
following list may not be all-inclusive:
Psychiatry and Psychology Services Limitations & Exclusions (AL, AK, AZ,
AR, CT, FL, GA, ID, IL, IN, IA, KS, KY, LA, ME, MA, MI, MN, MS, MO, MT, NC,
ND, NE, NH, NJ, NY, OH, OR, RI, SC, SD, TN, UT, VT, VA, VI, WA, WV, WI,
WY)

The member has a diagnosis of severe and profound Mental
Retardation (318.1, 318.2, and 319).

Any diagnostic or psychotherapeutic procedure rendered by a
practitioner not practicing within the scope of his/her licensure or other
State authorization.

Outpatient hospital services provided during inpatient services or under
the auspices of an excluded inpatient unit, residential treatment center,
residential facility or skilled nursing facility.
Outpatient Services
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
Day care programs, which provide primarily social, recreational, or
diversional activities, custodial or respite care.

Services to a skilled nursing facility resident that should be expected to
be provided by the nursing facility staff.

Vocational training when services are related solely to specific
employment opportunities, work skills, or work settings.

Biofeedback training for psychosomatic conditions.

Recovery meetings such as Alcoholics Anonymous, 12 Step, Alanon,
Narcotics Anonymous, due to their free availability in the community.

Telephone calls to patients, collateral resources and agencies.

Evaluation of records, reports, tests and other data.

Explanation of results of tests to family, employers or others.

Preparation of reports for agencies, courts, schools, or insurance
companies, etc. for medicolegal or informational purposes.

Screening procedures provided routinely to patients without regard to
the signs and symptoms of the patient’s mental illness.

Meals and transportation

Supervision or administration of self-administered medications and
supplying medications for home use.

Evaluations of mental status billed as psychological testing.
Psychotherapy Services Limitations & Exclusions (FL, PR, VI, DE, DC, MD,
NJ & PA)

Individual Psychotherapy is not covered when:
o Psychotherapy is rendered to a patient who has a
medical/neurological condition such as dementia, delirium or
other psychiatric conditions, which have produced a severe
enough cognitive deficit to prevent effective communication with
interaction of sufficient quality to allow insight oriented therapy
(i.e. behavioral modification techniques, interpersonal
psychotherapy techniques, supportive therapy or
cognitive/behavioral techniques).
o Psychotherapy that primarily includes the teaching of grooming
skills, monitoring activities of daily living, recreational therapy
(dance, art play), or social interaction.

Group psychotherapy is not covered when:
Outpatient Services
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Coverage Determination Guideline
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o The patient has a medical/neurological condition such as
Dementia, Delirium, or other psychiatric conditions, which have
produced a severe enough cognitive deficit to prevent effective
communication including interaction of sufficient quality with the
therapist and members of the group.
o Group services that include music therapy, socialization,
recreational activities/recreational therapy, art classes/art
therapy, excursions, sensory stimulation, eating together,
cognitive stimulation, or motion therapy.

Family psychotherapy is not covered when:
o The patient has certain medical conditions, (e.g., the patient is
unconscious or comatose) preventing the member from
participating in family therapy.
o The use of CPT code 90849 (multiple family group
psychotherapy)

Psychoanalysis (90845) is not covered when:
o Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP)
submit for the payment of psychoanalysis.
o The use of Psychoanalysis when psychoses are present.
o Provided by a provider not trained by an accredited
psychoanalysis program.

Psychopharmacologic Management without Psychotherapy (M0064) is
not covered when:
o Services include the administration, supply or observation of
oral medication for home use.
PART II: COVERAGE CRITERIA
1. Psychiatry and Psychology Services (AL, AK, AZ, AR, CT, FL, GA, ID, IL,
IN, IA, KS, KY, LA, ME, MA, MI, MN, MS, MO, MT, NC, ND, NE, NH, NJ,
NY, OH, OR, RI, SC, SD, TN, UT, VT, VA, VI, WA, WV, WI, WY)
1.1.
Psychiatry and Psychology Services must meet the following criteria:
1.1.1.
Services are delivered by a CMS qualified provider
(psychiatrists, clinical psychologists, clinical social workers,
psychiatric nurse practitioners, and clinical nurse specialists)
and delivered under an individualized written plan of
treatment.
1.1.2.
The treatment plan states the type, amount, frequency and
duration of services to be furnished indicating the diagnosis
and anticipated goals.
Outpatient Services
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1.2.
Services are for the purpose of diagnostic study or reasonably
expected to improve the member’s condition; and.
1.2.1.
"Improvement" in this context is measured by comparing the
effect of continuing treatment versus discontinuing it. Where
there is a reasonable expectation that if treatment services
were withdrawn the patient's condition would deteriorate,
relapse further, or require hospitalization, this criterion would
be met.
1.3.
Treatment is designed to reduce or control the member’s psychiatric
symptoms so as to prevent relapse or hospitalization and improve or
maintain the member’s level of functioning; and
1.4.
Treatment improves or maintains the patient’s level of functioning; and
1.4.1.
1.5.
Although it may be appropriate, it is not necessary for the
goal to be to restore the patient’s level of functioning prior to
the onset of illness.
For patients with long-term or chronic conditions, the control of
symptoms and maintenance of functioning to avoid further
deterioration or hospitalization is considered “improvement”; and
1.5.1.
Patients may increase their level of functioning, but reach a
point where further significant increase in functioning is not
expected.
1.6.
When stability can be maintained without further treatment/less
intensive treatment, services are no longer necessary; and
1.7.
Frequency and duration of services should include the consideration of
the following factors:
1.7.1.
Nature of the illness, prior history, goals of treatment and the
patient’s response.
1.7.2.
If evidence of improvement continues with implementation of
the treatment plan and the frequency of services is within
accepted norms of medical practice, coverage may continue.
1.7.3.
When a patient reaches a point in his/her treatment where
further improvement does not appear to be indicated and
there is no reasonable expectation of further improvement,
the services are no longer considered reasonable or
necessary.
2. Psychiatric Diagnostic Evaluation and Psychotherapy
Services/Procedure Codes (AR, CO, DE, DC, FL, LA, MD, MI, NM, NJ, OK,
PA, PR, TX, VI)
2.1.
Providers of Mental Health Services include:
Outpatient Services
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2.2.
2.3.
2.4.
2.1.1.
Psychiatrists, clinical psychologists, clinical social workers,
psychiatric nurse practitioners, and clinical nurse specialists.
2.1.2.
For approved providers of mental health services, the State
licensure or authorization must specify that the provider’s
scope of practice includes the provision of clinical
psychotherapy for the treatment of mental illness. It is the
responsibility of providers to be aware of their own State
licensure laws and written agreements and/or protocols
required, including changes as they occur.
2.1.3.
Coverage for all non-physician practitioners is limited to
services which they are authorized to perform by the State in
which they practice.
Psychiatric Diagnostic Evaluation (90791) is covered when:
2.2.1.
The patient has a psychiatric illness and /or is demonstrating
emotional or behavioral symptoms sufficient to cause
inappropriate behavior patterns or maladaptive functioning in
personal or social settings which may be suggestive of a
psychiatric illness; and/or
2.2.2.
Baseline functioning is altered by suspected illness or
symptoms.
Psychiatric Diagnostic Evaluation with Medical Services (90792) is
covered when:
2.3.1.
A member has an organic medical diagnosis and a
behavioral health condition is suspected; or
2.3.2.
If the patient had a previous established neurological
disorder and there has been an acute or marked mental
status change, or a second opinion or diagnostic clarification
is necessary to rule out additional psychiatric or neurological
processes.
Individual Psychotherapy (90832-90838) is covered when:
2.4.1.
The patient has a psychiatric illness and/or is demonstrating
emotional or behavioral symptoms sufficient to cause
inappropriate behavior or maladaptive functioning; and
2.4.2.
Psychotherapy services are performed by a person licensed
by the State where practicing, and whose training and scope
of practice allow that person to perform such services; and
2.4.3.
Psychotherapy is provided as an integral part of an active
treatment plan for which it is directly related to the patient’s
identified condition/diagnoses.
Outpatient Services
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2.5.
2.6.
2.4.4.
Some patients require psychotherapy alone or along with
medical evaluation and management services. These
services involve a variety of responsibilities unique to the
medical management of psychiatric patients such as medical
diagnostic evaluation (i.e. evaluation of co-morbid medical
conditions, drug interactions, and physical examinations),
drug management physician orders, interpretation of
laboratory or other diagnostic studies and observations.
2.4.5.
The patient is amenable to allowing insight-oriented therapy
such as behavioral modification techniques, interpersonal
psychotherapy techniques, supportive therapy, and
cognitive/behavioral techniques to be effective.
Group Psychotherapy (90853) (DE, DC, MD, NJ, and PA) is covered
when:
2.5.1.
The patient has a psychiatric illness and /or is demonstrating
emotional or behavioral symptoms sufficient to cause
inappropriate behavior patterns or maladaptive functioning in
personal or social settings; and
2.5.2.
The issues presented and explored in the group setting
should evolve towards a theme or a therapeutic goal; and
2.5.3.
Group psychotherapy is ordered by a provider as an integral
part of an active treatment plan for which it is directly related
to the patient’s identified condition/diagnosis; and
2.5.4.
This treatment plan is adhered to and is endorsed and
monitored by the treating physician or physician of record;
and
2.5.5.
The mental health care professional has obtained
specialized skills as required.
Family Psychotherapy (90846, 90847) (DE, DC, MD, NJ, and PA) is
covered when:
2.6.1.
The primary purpose of therapy is the treatment or
management of the patient’s condition. Examples include:
2.6.2.
There is a need to observe and correct, through
psychotherapeutic techniques, the patient’s interactions with
family members; and/or
2.6.3.
There is a need to assess the conflicts or impediments within
the family, and assist, through psychotherapeutic
techniques, the family members in the management of the
patient; and
Outpatient Services
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2.7.
2.8.
2.9.
2.6.4.
Family psychotherapy is ordered by a provider as part of an
active treatment plan for which it is directly related to the
patient’s identified condition/diagnosis; and
2.6.5.
Family psychotherapy is conducted face to face by
physicians, psychologists, or other mental health
professionals licensed or authorized by State statutes.
Psychoanalysis (90845) (DE, DC, MD, NJ, and PA) is covered when:
2.7.1.
The medical record documents the indications for
psychoanalysis, description of transference, and the
psychoanalytic techniques used; and
2.7.2.
The provider is trained and credentialed in its use by an
accredited psychoanalysis program; and
2.7.3.
Psychoanalysis is billed once daily regardless of length of
the session (typically psychoanalysis sessions are 45-50
minutes in length).
Interactive Complexity Services (90785) are covered when (90785)
is used in conjunction with other codes listed below:
2.8.1.
Diagnostic evaluation (90791, 90792)
2.8.2.
Psychotherapy (90832, 90834, 90837)
2.8.3.
Psychotherapy when performed with an evaluation and
management services (90833, 90836, 90838, 99201-99255,
99304-99337, 99341-99350)
2.8.4.
Group psychotherapy (90853)
2.8.5.
The above codes may be used with (90785) when:
2.8.5.1.
There is a need to manage maladaptive communication
that complicates the delivery of care; and/or
2.8.5.2.
Caregiver emotions or behaviors interfere with
implementation of the treatment plan; and/or
2.8.5.3.
Evidence or disclosure of sentinel event and reporting to
a third party is mandated; and/or
2.8.5.4.
There is a need for the use of play equipment, physical
devices, interpreter, or translator to overcome barriers to
diagnostic or therapeutic interaction with a patient who is
not fluent in the same language or has not developed or
has lost expressive or receptive language skills to use or
understand typical language.
Psychotherapy for Crisis (90839, 90840) is covered when:
Outpatient Services
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2.9.1.
The presenting problem is typically life threatening or
complex and requires immediate attention to a patient with
high distress; and
2.9.2.
The crisis codes are used to report the total face-to-face with
the patient and/or family with the physician or other qualified
health care professional providing psychotherapy for crisis,
even if the time spent on that date is not continuous; and
2.9.3.
For any given period of time spent providing psychotherapy
for crisis, the physician or other qualified health care
professional must devote his or her full attention to the
patient and, therefore, cannot provide service to any other
patient during the same time period.
2.10. Other Psychiatric Services or Procedures (DE, DC, MD, NJ, and
PA) Includes:
2.10.1.
Narcosynthesis (90865) used for the administration of
sedative or tranquilizer drugs, usually intravenously, to relax
the patient and remove inhibitions for discussion of subjects
difficult for the patient to discuss freely in the fully conscious
state. Narcosynthesis is covered when:
2.10.1.1. The record reflects medical necessity (i.e., the patient
had difficulty verbalizing about psychiatric problems
without the aid of the drug) and document the specific
pharmacological agent, dosage, and whether the
technique was effective.
2.10.1.2. Only physicians may administer narcosynthesis.
2.11. Psychological Services Under the Incident to Provision (IL, IN, IA,
KS, KY, MI, MN, MO, NE, WI) These services refer to psychological
services provided “incident to” a psychiatrist’s services furnished as an
integral, although incidental part of the psychiatric services provided in
the course of diagnosis or treatment.
2.11.1.
Only the following types of individuals, when they are
performing within their scope of clinical practice as
authorized under State law, are qualified to perform the
indicated services under the “incident to” provision in an
office or other outpatient facility:
2.11.1.1. Doctorate or Masters Level Clinical Psychologist
2.11.1.2. Doctorate or Masters Level Clinical Social Worker
2.11.1.3. Clinical Nurse Specialist (CNS)
2.11.1.4. Nurse Practitioner (NP)
Outpatient Services
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2.11.1.5. Masters level Licensed Marriage and Family Therapist
(Iowa, Indiana, Kansas, Nebraska, Michigan, Missouri)
2.11.1.6. Licensed Clinical Professional Counselors (LCPC) (Iowa,
Indiana, Kansas, Nebraska, Michigan, Missouri)
2.11.2.
In order for services to be covered under the “incident to”
provision:
2.11.2.1. The services must be a part of an integral part of the
member’s normal course of treatment; and
2.11.2.2. The physician has personally performed the initial service
and remains actively involved in the course of treatment;
and
2.11.3.
The physician remains available to provide direct supervision
and services to the member as necessary.
PART III: CLINICAL BEST PRACTICE & DOCUMENTATION
Evaluation and Treatment Planning
1. The medical record should indicate the presence of a psychiatric illness
and/or demonstration of emotional or behavioral symptoms which may be
suggestive of a psychiatric illness or altered baseline functioning. The
evaluation should include:
1.1. Reason for the evaluation/chief complaint
1.2. Referral source
1.3. History of present illness, including length of existence of
problems/symptoms/conditions
1.4. Past history
1.5. Significant medical history and current medications
1.6. Social, family history
1.7. Mental status exam
1.8. Strengths/abilities
1.9. Diagnostic impression list
2. The treatment plan should include methods of therapy, anticipated length of
treatment to the extent possible, and a description of the planned measurable
and objective goals related to expected changes in behavior or thought
processes.
3. Psychotherapy services should be documented to include:
Outpatient Services
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3.1. A detailed summary of each session, including descriptive documentation
of therapeutic interventions such as examples of attempted behavior
modification, supportive interaction and discussion of reality.
3.2. The degree of patient participation and interaction with the therapist, the
reaction of the patient to the therapy session, documentation toward goal
oriented outcomes and the changes or lack of changes in patient
symptoms and/or behavior as a result of the therapy session.
3.3. The rationale for any departure from the plan or extension of therapy
should be documented in the medical record. The therapist should
document patient/therapist interaction in addition to an assessment of the
patient’s problems.
3.4. When outpatient psychiatric services are provided at a high frequency or
long duration, the plan of treatment, progress notes, and condition of the
patient should justify the intensity of services rendered.
3.5. There should be documentation of the patient’s capacity to participate in
and benefit from psychotherapy, especially if the patient is in any way
cognitively impaired.
3.6. The record should indicate target symptoms, goals of therapy and
methods of monitoring outcome.
3.7. There should be documentation of how the treatment is expected to
improve the health status or function of the patient.
PART IV: ADDITIONAL RESOURCES
Clinical Protocols
Optum maintains clinical protocols that include the Level of Care Guidelines and
Best Practice Guidelines which describe the scientific evidence, prevailing
medical standards and clinical guidelines supporting our determinations
regarding treatment. These clinical protocols are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals
on ubhonline
Peer Review
Optum will offer a peer review to the provider when services do not appear to
conform to this guideline. The purpose of a peer review is to allow the provider
the opportunity to share additional or new information about the case to assist
the Peer Reviewer in making a determination including, when necessary, to
clarify a diagnosis
Second Opinion Evaluations
Outpatient Services
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Optum facilitates obtaining a second opinion evaluation when requested by an
enrollee, provider, or when Optum otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment
planning and care for the member.
Referral Assistance
Optum provides assistance with accessing care when the provider and/or
enrollee determine that there is not an appropriate match with the enrollee’s
clinical needs and goals, or if additional providers should be involved in delivering
treatment.
PART V: DEFINITIONS
Diagnostic and Statistical Manual of the American Psychiatric Association
(DSM) A manual produced by the American Psychiatric Association which
provides the diagnostic criteria for mental health and substance use disorders,
and other problems that may be the focus of clinical attention. Unless otherwise
noted, the current edition of the DSM applies.
Family Psychotherapy is a specialized therapeutic technique for treating the
identified patients’ mental illness by intervening in a family system in such a way
as to modify the family structure, dynamics, and interactions which exert
influence on the patient’s emotions and behaviors lasting 40-50 minutes per
session.
Group Psychotherapy is a form of treatment administered in a group setting led
by a person, authorized by state statute to perform this service (i.e., psychiatrist,
clinical psychologist, licensed clinical social worker, certified nurse practitioner, or
clinical nurse specialist). The group (maximum 12 patients) meets for a
prescribed period of time during which common issues are presented and
generally relate to a therapeutic goal. Medical diagnostic evaluation and
pharmacological management may continue by a physician when indicated.
Interactive Complexity Services refers to specific communication factors that
complicate the delivery of a psychiatric service. Commonly these include difficult
communication with discordant or emotional family members and engagement of
young and verbally undeveloped or impaired patients.
Mental Health/Substance Use Disorder Designee The organization or
individual, designated by Optum, that provides or arranges Mental Health
Services and Substance Use Disorder Services for which Benefits are available
under the policy.
Mental Illness Those mental health or psychiatric diagnostic categories that are
listed in the current Diagnostic and Statistical Manual of the American Psychiatric
Association, unless those services are specifically excluded under the Policy.
Outpatient Services
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Optum is a brand used by United Behavioral Health and its affiliates.
Psychoanalysis is a treatment modality that uses specialized techniques to gain
insight into a patient’s unconscious motivations and conflicts using the
development and resolution of a therapeutic transference to achieve therapeutic
effect. It is a different modality than psychotherapy.
Psychopharmacologic Medication Management Medication management
involves monitoring or changing psychopharmacologic medication.
Psychotherapy for Crisis is an urgent assessment and history of a crisis state,
a mental status exam, and a disposition. The treatment includes psychotherapy,
mobilization of resources to defuse the crisis and restore safety, and
implementation of psychotherapeutic interventions to minimize the potential for
psychological trauma.
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,
facilitate coping mechanisms and/or encourage personality growth and
development.
PART VI: REFERENCES
1. Centers for Medicare and Medicaid Services, Benefit Policy Manual, 2014,
retrieved 8/13/15 from www.cms.gov
2. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Outpatient Psychiatry and Psychology Services, L31887-CGS Administrators
Kentucky & Ohio retrieved 8/13/15 from www.cms.gov.
3. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatric Codes, L32766-Novitas, Arkansas, Colorado, Louisiana, New
Mexico, Mississippi, Oklahoma, Texas, retrieved 8/13/15 from www.cms.gov.
4. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatric Diagnostic Evaluation and Psychotherapy Services, L33128-First
Coast Service Options, Florida, Puerto Rico, Virgin Islands retrieved 8/13/15
from www.cms.gov.
5. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatric Diagnostic Evaluation and Psychotherapy Services, L33130-First
Coast Service Options, Florida, Puerto Rico, Virgin Islands, retrieved 8/13/15
from www.cms.gov.
6. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatric Therapeutic Procedures, L27514-Novitas, Delaware, District of
Columbia, Maryland, New Jersey, Pennsylvania, retrieved 8/13/15 from
www.cms.gov.
Outpatient Services
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Confidential and Proprietary, © Optum 2015
Optum is a brand used by United Behavioral Health and its affiliates.
7. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatry and Psychology Services, L26895-National Government Services,
Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire,
New York, Rhode Island, Vermont, Wisconsin, retrieved 8/15/15 from
www.cms.gov.
8. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatry and Psychology Services, L29834 (not found)retrieved 4/10/14
from www.cms.gov.
9. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychiatry and Psychology Services, L30489-Wisconsin Physicians Service,
Alaska, Alabama, Arkansas, Arizona, Connecticut, Florida, Georgia, Iowa,
Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maine,
Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, North
Dakota, Nebraska, New Hampshire, New Jersey, Ohio, Oregon, Rhode
Island, South Carolina, South Dakota, Tennessee, Utah, Virginia, Virgin
Islands, Vermont, Washington, Wisconsin, West Virginia, Wyoming, retrieved
8/13/15 from www.cms.gov.
10. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychological Services Under the Incident to Provision, L30715-Wisconsin
Physicians Service, Indiana, Iowa, Kansas, Michigan, Missouri, Nebraska,
retrieved 8/13/15 from www.cms.gov.
11. Centers for Medicare and Medicaid Services, Local Coverage Determination,
Psychological Services Under the Incident to Provision, L31892-CGS
Administrators, Kentucky, Ohio, retrieved 8/13/15 from www.cms.gov.
PART VI: CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the
service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document.
Limited to specific CPT and HCPCS codes?
90791
90791 plus interactive add-on code (90785)
90832
90832 plus interactive add-on code (90785)
90832 plus pharmacological add-on code
(90863)
90834
90834 plus interactive add-on code (90785)
90834 plus pharmacological add-on code
(90863)
90837
X Yes  No
Psychiatric diagnostic evaluation
Psychiatric diagnostic evaluation (interactive)
Psychotherapy, 30 minutes with patient and/or
family
Psychotherapy, 30 minutes with patient and/or
family (interactive)
Psychotherapy, 30 minutes with patient and/or
family (pharmacological management)
Psychotherapy, 45 minutes with patient and/or
family member
Psychotherapy, 45 minutes with patient and/or
family member (interactive)
Psychotherapy, 45 minutes with patient and/or
family member (pharmacological management)
Psychotherapy, 60 minutes with patient and/or
Outpatient Services
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Coverage Determination Guideline
Confidential and Proprietary, © Optum 2015
Optum is a brand used by United Behavioral Health and its affiliates.
90837 plus interactive add-on code (90785)
90837 plus pharmacological add-on code
(90863)
90839
90839 plus interactive add-on code (90785)
90845
90846
90847
90849
90853
90853 plus interactive add-on code (90785)
90865
90880
G0410
G0411
family member
Psychotherapy, 60 minutes with patient and/or
family member (interactive)
Psychotherapy, 60 minutes with patient and/or
family member (pharmacological management)
Psychotherapy for crisis, first 60 minutes
Psychotherapy for crisis, first 60 minutes
(interactive)
Psychoanalysis
Family psychotherapy without the patient
present
Family psychotherapy, conjoint psychotherapy
with the patient present
Multiple-family group psychotherapy
Group psychotherapy (other than of a multiplefamily group)
Group psychotherapy (other than of a multiplefamily group) (interactive)
Narcosynthesis for diagnostic and therapeutic
purposes
Hypnotherapy for diagnoses codes 300.00;
300.11-300.15; 300.21-300.23; 300.29; 307.80;
307.89; 308.3; 308.4; 308.9; 309.0; 309.1;
309.21; 309.24; 309.28; 309.3; 309.4; 309.81;
309.9
Group psychotherapy other than of a multiple
family group, in a partial hospitalization setting,
approximately 45 to 50 minutes
Interactive group psychotherapy, in a partial
hospitalization setting, approximately 45 to 50
minutes
Limited to specific diagnosis codes?
□
YES
x
Limited to place of service (POS)?
x
YES
□
NO
Limited to specific provider type?
x
YES
□
NO
Limited to specific revenue codes?
□
YES
x
NO
NO
Outpatient; Outpatient Hospital Facilities
PART VII: HISTORY
Revision Date
Name
Revision Notes
Outpatient Services
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Coverage Determination Guideline
Confidential and Proprietary, © Optum 2015
Optum is a brand used by United Behavioral Health and its affiliates.
4/2014
8/2015
L. Urban
L. Urban
Version 1-Final
Version 2-Final
The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations.
These Coverage Determination Guidelines are believed to be current as of the date noted.
Outpatient Services
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Coverage Determination Guideline
Confidential and Proprietary, © Optum 2015
Optum is a brand used by United Behavioral Health and its affiliates.