* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Psychiatric and Psychological Outpatient Services
Clinical psychology wikipedia , lookup
Clinical mental health counseling wikipedia , lookup
Anti-psychiatry wikipedia , lookup
History of mental disorders wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Moral treatment wikipedia , lookup
Involuntary commitment internationally wikipedia , lookup
Mental health in Russia wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Lifetrack Therapy wikipedia , lookup
Mental status examination wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Psychiatric rehabilitation wikipedia , lookup
Outpatient commitment wikipedia , lookup
Mental health professional wikipedia , lookup
Abnormal psychology wikipedia , lookup
Psychotherapy wikipedia , lookup
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 Page 1 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 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 Page 2 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 3 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 4 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 5 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 6 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 7 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 8 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 9 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 10 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 11 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 12 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 13 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates. 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 Page 14 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 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 Page 15 of 18 Coverage Determination Guideline 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 Page 16 of 18 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 Page 17 of 18 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 Page 18 of 18 Coverage Determination Guideline Confidential and Proprietary, © Optum 2015 Optum is a brand used by United Behavioral Health and its affiliates.