Psychotherapy Services

Table of Contents

• Regulations and Targeted Probe and Educate Resources
  • Medicare Regulations
  • CMS TPE Resources
  • NGS Resources
• Psychotherapy Treatment Plans
  • Required Treatment Plan Components
• Signing the Psychotherapy Treatment Plan

Regulations and Targeted Probe and Educate Resources

Medicare Regulations

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1
• Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632)
• Local Coverage Article: Billing and Coding: Psychiatry and Psychology Services (A56937)
• Local Coverage Article: Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)

CMS Targeted Probe and Educate Resources

• Targeted Probe and Educate
• Improving the Medicare Claims Review Process (TPE)
• Targeted Probe and Educate (TPE) Q&As

NGS Resources

• Best Practices for Successful TPE
• Targeted Probe and Educate Review Topics
• TPE Manual
• About Appeals
• NGSConnex
• Education Events

Psychotherapy Treatment Plans

Psychotherapy treatment plans have no required format. The plan can be on its own document, or the components can be embedded in/throughout a progress or visit note.

Required Treatment Plan Components

The required treatment plan components include:

• Type: You must state the type of therapy (so specifically saying individual or group) this cannot be something that is implied or assumed based on documentation submitted.
• Amount: Include the intended amount of therapy planned– meaning the planed length of the sessions. If there is a variance in the actual length in session provided, this would not result in a denial. If you find the planned length of sessions needs to be adjusted, you may update your treatment plan to reflect the change.
• Frequency: The anticipated frequency of the sessions, such as weekly or monthly.
• Duration: The duration that the treatment plan will be valid or effective for (It is the responsibility of the provider to update these when the due date specified is reached) Medicare does not specify how long a treatment plan may be valid for. Our reviewers will review based on the dates provided on the treatment plan itself. Please ensure the treatment plan components are up to date at all times and abide by your state rules and regulations for other timeframe requirements. (We cannot provide guidance on requirements unrelated to Medicare.)
• Diagnosis: The mental health or psychiatric diagnosis being treated. If a diagnosis has not been identified at the time the treatment plan is established, please describe the patient's condition for which the service is necessary. This could look like: stating what the current signs and symptoms are that are being addressed or the patient's suspected psychiatric diagnosis if known. Additionally, please specify that the diagnosis is TBD (this is only acceptable for the first treatment plan, notes can support working toward a definitive diagnosis. Once diagnosis is identified– the plan should be updated/validated as soon as practical.)
• Anticipated Goals: List the intended individualized outcomes and goals to be achieved by the interventions planned.

Signing the Psychotherapy Treatment Plan 

• The psychotherapy treatment plan must be signed.
• Part A and Part B requirements can change dependent upon billing (for example: billing incident to)
• A physician does not necessarily have to sign a treatment plan.
• For Part A - The following individuals can sign a treatment plan:
  • Physician (MD/DO)
  • Clinical Psychologist
  • Nurse Practitioner
  • Clinical Nurse Specialists
  • Physician Assistants
  • *Clinical Social Workers/Marriage and Family Therapists/Mental Health Counselors
• All other licensed clinicians providing psychotherapy services not listed above must have a “physician” provide the initial evaluation and sign the treatment plan. In these circumstances “physician” is defined as physician /psychologists or other practitioner (PA, NP, CNS, CNM).
• Visit notes do not need co-signing.

*CSWs/MFTs/MHCs are able to see the patient initially, author and sign the treatment plan so as those individuals will be the clinicians that provide the psychotherapy services to the beneficiary. (No one else will be able to see the beneficiary utilizing the treatment plan established and signed by these individuals). Medicare does not cover services provided incident to a CSW/MFT/MHC. 

Posted 9/4/2024