Mental Health

Mental Health Services

Table of Contents

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Psychiatric Diagnostic Procedures: 90791‒90792

The psychiatric diagnostic procedure codes require the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient’s ability and capacity to respond to treatment, and an initial plan of treatment. Information may be obtained from not only the patient, but also other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history.

  • 90791 ‒ Psychiatric diagnostic evaluation
  • 90792 ‒ Psychiatric diagnostic evaluation with medical services

Note: Codes 90791 and 90792 may be reported once per day and not on the same day as an E/M service performed by the same individual for the same patient.

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Interactive Complexity: 90785

Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients.

The interactive complexity component code 90785 may be used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792) and psychotherapy (90832, 90834, 90837), psychotherapy when performed with an E/M service (90833, 90836, 90838) and group psychotherapy (90853).

The code is used principally to evaluate children and also adults who do not have the ability to interact through ordinary verbal communication. The healthcare provider uses inanimate objects, such as toys and dolls for a child, physical aids and nonverbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or one who does not speak the same language as the healthcare provider.

Interactive complexity may also be used in the evaluation of adult patients with organic mental deficits, or for those who are catatonic or mute.

Interactive complexity may be reported with psychotherapy when at least one of the following is present:

  • Maladaptive communication (e.g., high anxiety, high reactivity, repeated questions or disagreement)
  • Emotional or behavioral conditions inhibiting implementation of treatment plan
  • Mandated reporting/event exists (e.g., abuse or neglect) or
  • Play equipment, devices, interpreter, or translator required due to inadequate language expression or different language spoken between patient and professional

Documentation

The medical record must reflect the elements outlined in the above description and must be rendered by a qualified provider (see “Limitations” subsection below). Additionally, the medical record must include adaptations utilized in the session and the rationale for employing these interactive techniques. The medical record must include treatment recommendations.

  • 90785 ‒ Interactive complexity (List separately in addition to the code for primary procedure)

Note: This code should not be used if the patient is capable of ordinary verbal communication.

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Psychotherapy: 90832‒90838

Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified health professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.

The psychotherapy service codes 90832‒90838 include ongoing assessment and adjustment of psychotherapeutic interventions, and may include involvement of family member(s) or others in the treatment process. Psychotherapy times are for face-to-face services with the patient and\or family member. The patient must be present for all or some of the service. For family psychotherapy without the patient present, use 90846.

Some psychiatric patients receive a medical E/M service on the same day as a psychotherapy service by the same physician or other qualified health care professional. To report both E/M and psychotherapy, the two services must be significant and separately identifiable. These services are reported by using codes specific for psychotherapy when performed with E/M services (90833, 90836 and 90838) as add-on codes to the E/M service.

Documentation

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the medical record. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.

Comments

While a variety of psychotherapeutic techniques are recognized for coverage under these codes, the services must be performed by persons authorized by their state to render psychotherapy services. Healthcare providers would include: physicians, clinical psychologists, registered nurses with special training (as described in the “Indications” section), and clinical social workers. Medicare coverage of procedure codes 90832‒90838 does not include teaching grooming skills, monitoring ADL, recreational therapy (dance, art, play) or social interaction. Therefore, procedure codes 90832‒90838 should not be used to bill for ADL training and/or teaching social interaction skills.

Psychotherapy codes that include an E/M component are payable only to physicians, NPs and CNSs. The E/M component of the services must be documented in the record. A psychotherapy code should not be billed when the service is not primarily a psychotherapy service, that is, when the service could be more accurately described by an E/M or other code.

The duration of a course of psychotherapy must be individualized for each patient. Prolonged treatment may be subject to medical necessity review. The provider must document the medical necessity for prolonged treatment.

  • 90832 ‒ Psychotherapy, 30 minutes with patient and/or family member
  • 90833 ‒ Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  • 90834 ‒ Psychotherapy, 45 minutes with patient and/or family member
  • 90836 ‒ Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  • 90837 ‒ Psychotherapy, 60 minutes with patient and/or family member
  • 90838 ‒ Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

The duration of a course of psychotherapy must be individualized for each patient. Prolonged treatment may be subject to medical necessity review. The provider must document the medical necessity for prolonged treatment.

Note: The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision-making. A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.

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Psychotherapy for Crisis: 90839‒90840

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. The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress.

Documentation

The record must indicate that the guidelines under the “Description” and “Comments” sections were followed.

Comments

“Codes 90839, 90840 are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, 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. The patient must be present for all or some of the service.” (CPT 2015, Professional Edition, p.559)

  • 90839 - Psychotherapy for crisis; first 60 minutes
  • 90840 ‒ each additional 30 minutes (List separately in addition to code for primary service)

Note: Use 90840 in conjunction with 90839. Do not report 90839, 90840 in conjunction with 90791, 90792, psychotherapy codes 90832-90838 or other psychiatric services, or 90785‒90899

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Mobile Psychotherapy for Crisis Services: G0017-G0018

Effective Date 1/1/2024

Payment for these psychotherapy for crisis services is equal to 150% of the fee schedule amount for services furnished in nonfacility sites of service-other than office setting (including the home or mobile unit).

  • G0017- Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the nonfacility rate for psychotherapy for crisis services applies, other than the office setting); first 60 minutes
  • G0018- Psychotherapy for crisis furnished in an applicable site of service; each additional 30 minutes (list separately in addition to code for primary service)

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Family Medical Psychotherapy: 90846, 90847, 90849

Family psychotherapy describes the treatment of the family unit when maladaptive behaviors of family members are exacerbating the beneficiary’s mental illness or interfering with the treatment, or to assist the family in addressing the maladaptive behaviors of the patient and to improve treatment compliance.

Indications of Coverage

Family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient’s condition. Examples include:

  • When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members
  • Where there is a need to assess the conflicts or impediments within the family and assist through psychotherapy, the family members in the management of the patient

The term “family” may apply to traditional family members, live-in companions, or significant others involved in the care of the patient. Codes 90846 and 90847 do not pertain to consultation and interaction with paid staff members at an institution. Facility staff members are not considered significant others.

Code 90849 represents multiple-family group psychotherapy and is generally noncovered by Medicare. Such group therapy is usually directed to the effects of the patient’s condition on the family and its purpose is to support the affected family members. Therefore, code 90849 does not meet Medicare’s standards of being a therapy primarily directed toward treating the beneficiary's condition. Claims for 90849 may be approved on an individual consideration basis.

  • 90846 ‒ Family Psychotherapy (without the patient present)
  • 90847 ‒ Family Psychotherapy (with the patient present)
  • 90849 ‒ Multiple-family group psychotherapy

Note: Family medical psychotherapy is neither a treatment for the relatives, nor treatment for an individual family member’s problem. Multiple family group psychotherapy has restricted coverage. Documentation must be submitted.

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Group Psychotherapy: 90853

Group psychotherapy is a form of treatment in which a carefully selected group of patients are guided by a licensed psychotherapist for the purpose of helping to effect changes in maladaptive patterns which interfere with social functioning and are associated with a diagnosable psychiatric illness.

Description

Code 90853 represents psychotherapy administered in a group setting, involving no more than 12 participants, facilitated by a trained therapist simultaneously providing therapy to these multiple patients. The group therapy session typically lasts 45 to 60 minutes. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support.

  • 90853 ‒ Group psychotherapy (other than of a multiple-family group)

Note: Group psychotherapy must document the actual number of participants at each session. Use 90853 in conjunction with 90785 when the patient or patients in the group setting do not have the ability to interact by ordinary verbal communication and therefore, nonverbal communication skills are employed or an interpreter may be necessary.

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Psychoanalysis: 90845

Procedure code 90845 involves the practice of psychoanalysis using special techniques to gain insight into and treat a patient’s unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.

  • 90845 ‒ Psychoanalysis

Note: The medical record must document the indications for psychoanalysis, description of the transference and the psychoanalytic techniques used.

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Electroconvulsive Therapy: 90870

Electroconvulsive therapy is the application of electric current to the brain, through scalp electrodes to induce a single seizure to produce a therapeutic effect. It is used primarily to treat major depressive disorder when antidepressant medication is contraindicated and for certain other clinical conditions.

  • 90870 ‒ Electroconvulsive therapy (includes necessary monitoring)

Note: When a psychiatrist performs both the ECT and the associated anesthesia, no separate payment is made for the anesthesia. Code 90870 is limited to use by physicians (MD/DO) only.

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Central Nervous System Assessments/Tests: (e.g., Neuro-Cognitive, Mental Status, Speech Testing)

CPT codes 96105, 96112, 96113, 96116, 96121, 96130, 96131, 93136, 96137, 96138, 96139, 96146 and G0451 require the submission of any ICD-10-CM code that is consistent with the indications of coverage.

For dates of service on or after 1/1/2019 the following codes were deleted: 96101, 96102, 96103, 96111, 96118, 96119 and 96120.

  • 96101 ‒ for psychological testing by a psychologist or physician is replaced by 96130 and 96131 for psychological testing evaluation services and 96136 and 96137 for test administration and scoring
  • 96102 ‒ for psychological testing by a technician is replaced by 96130 and 96131 for psychological testing evaluation services and 96138 and 96139 for test administration and scoring
  • 96118 ‒ for neuropsychological testing by a psychologist or physician is replaced by 96132 and 96133 for neuropsychological testing evaluation services and 96136 and 96137 for test administration and scoring
  • 96119 ‒ for neuropsychological testing by a technician is replaced by 96132 and 96133 for neuropsychological testing evaluation services and 96138 and 96139 for test administration and scoring

The new codes are based on the date of service, not the date the claim is submitted.

Description

Codes 96130, 96131, 96136, 96137, 96138 and 96139 (psychological testing) include the administration, interpretation and scoring of the tests mentioned in the CPT descriptions and other medically accepted tests for evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation and other factors influencing treatment and prognosis.

Documentation

The medical record must indicate the presence of mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.

Comments

These codes do not represent psychotherapeutic modalities, but are diagnostic aids. Use of such tests when mental illness is not suspected would be a screening procedure not covered by Medicare. Each test performed must be medically necessary. Therefore, standardized batteries of tests are not acceptable unless each test in the battery is medically necessary.

Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing.

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Health and Behavior Assessment/Intervention: 96156‒96168

The event-based assessment service is conducted through health-focused clinical interviews, observation and clinical decision-making and billed with CPT code 96156.

Health and behavior assessment procedures are used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment or management of physical health problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.

Health and behavior intervention procedures are used to modify the psychological, behavioral, emotional, cognitive and social factors identified as important to or directly affecting the patient's physiological functioning, health and well-being, or specific disease-related problems.

The health and behavior assessment, initial and reassessment, should be reported with CPT code 96156. Intervention services should be reported with CPT codes 96158, 96159, 96164, or 96165.

  1. The patient has an underlying physical illness or injury, and
  2. There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or injury, and
  3. The patient is alert, oriented, and has the capacity to understand and respond meaningfully during the face-to-face encounter, and
  4. The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and
  5. The assessment is not duplicative of other provider assessments

In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patients capacity to understand and cooperate with the medical interventions necessary to their health and well-being.

Health and behavioral intervention, individual or group (two or more patients) CPT codes 96158, 96159, 96164, 96165 require that:

  1. Specific psychological intervention(s) and patient outcome goals(s) have been clearly identified, and
  2. Psychological intervention is necessary to address:
    • Noncompliance with the medical treatment plan, or
    • The biopsychosocial factors associated with the new diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health promoting behaviors, health related risk-taking behaviors, and overall adjustment to medical illness.

Health and behavioral intervention (with the family and patient present) CPT codes 96167, 96168 is considered reasonable and necessary for the patient who meets all of the following criteria:

  1. The family representative* directly participates in the overall care of the patient, and
  2. The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.

*For the purpose of this policy, all references to a family representative is defined as immediate family members only (i.e., husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular and sustained basis, or a guardian or healthcare proxy.

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Hypnotherapy: 90880

Hypnosis is an artificially induced alteration of consciousness in which the patient is in a state of increased suggestibility.

  • 90880 ‒ Hypnotherapy

Note: Medicare will consider hypnotherapy if reasonable and necessary for the treatment of a medical or psychological condition.

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Narcosynthesis: 90865

Procedure code 90865 is 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.

Documentation

The medical record should document the medical necessity of this procedure (e.g., the patient had difficulty verbalizing their psychiatric problems without the aid of the drug). The record should also document the specific pharmacological agent, dosage administered, and whether the technique was effective or noneffective.

Comments

Use of CPT code 90865 is restricted to physicians (MD/DO) only.

  • 90865 ‒ Narcosynthesis for psychiatric diagnostic and therapeutic purposes (e.g., sodium amobarbital [amytal] interview)

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Assignment of Claims

  • If a psychiatrist is a Medicare-participating physician who chooses to accept assignment for his or her services, assigned payment must be accepted for all covered services for all Medicare patients. If a psychiatrist chooses not to participate under Medicare, he or she can choose to accept assignment on a case-by-case basis. However, if this nonparticipating physician does not choose to accept assignment, payment is made at 95 percent of the Medicare PFS amount.
  • The services of CPs, CSWs, CNSs, MFTs, MHCs, NPs, PAs and CNMs are always subject to assignment. Accordingly, regardless of whether these NPP participate in the Medicare Program, payment for their services is always made under assignment.
  • IPPs who are authorized by Medicare to perform only diagnostic psychological and neuropsychological tests are not required to accept assigned payment for these tests. Therefore, payment for these tests is made to participating IPPs at 100 percent of the Medicare PFS amount and to nonparticipating IPPs at 95 percent of the Medicare PFS amount.
  • Assignment means that the provider or supplier will be paid the Medicare allowed amount as payment in full for his or her services; and
  • May not bill or collect from the patient any amount other than unmet copayments, deductibles, and/or coinsurance.

All services provided to Medicare patients must be furnished by practitioners who, by virtue of their specific state licensure, certification, and training, are professionally qualified to provide medically necessary services.

CMS requires that the following providers accept assignment:

  • CP ‒ clinical psychologist
  • CSW ‒ clinical social worker
  • MFT- marriage and family therapist
  • MHC – mental health counselor
  • PA ‒ physician assistant
  • NP ‒ nurse practitioner
  • CNS ‒ clinical nurse specialist
  • CNM ‒ certified nurse midwife

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Reimbursement Rate

The physician fee schedule is reviewed and revised annually. The Fee Schedule Lookup is published on our website. 

  • Physicians and NPPs please select the Medicare Physician Fee Schedule.
  • CPs, CSWs, MFTs, MHCs please select the CP/CSW Fee Schedule.

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Documentation of the Medical Record for Mental Health Claims

Please see LCD L33632 for Psychiatry and Psychology Services and Article A52434 for health and behavioral assessment/intervention.

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Excluded Information Per Privacy Rule (Psychotherapy Notes)

The HIPAA of 1996 has imposed specific restrictions on access to psychotherapy notes. These restrictions are outlined in the CFR, 45 CFR, parts 160 and 164 (The Privacy Rule). Providers are exempt from submitting psychotherapy notes without patient authorization when the notes in question fit the Privacy Rule definition in 45 CFR, Section 164.501. This section defines psychotherapy notes as “notes recorded by a mental health professional (in any medium) which document or analyze the contents of a counseling session and that are separated from the rest of a medical record.”

45 CFR, Section 164.501 states that “the provider is responsible for extracting information required to perform a review for medical necessity.” The provider, therefore, is expected to document information potentially necessary for review in a manner that will allow submission, if this information without release of psychotherapy details that are protected by the Privacy Rule.

This following information is excluded from the protected information in 45 CFR, Section 164.501, and must be included in all psychiatric medical record documentation and made available upon request:

  • Name of beneficiary and date of service
  • Type of service (individual, group, family, interactive, etc.)
  • Time element, where duration of the face-to-face contact is the determining factor for coding the service rendered
  • Modalities and frequency of treatment furnished
  • A clinical note for each encounter, where in the aggregate, summarizes the following items:
    • diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis and progress to date.
  • Elements such as treatment plans, functional status and prognostic assessment are expected to be documented, updated and available for review, but do not need to be delineated for each individual date of service
  • Identity and professional credentials of the person performing service

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Documentation of E/M Services

CMS established medical record documentation guidelines available in the 1995 Documentation Guidelines for Evaluation and Management Services and 1997 Documentation Guidelines for Evaluation and Management Services (595 KB). These guidelines are available on the AMA bulletin board, the CMS and National Government Services websites, or may be obtained by contacting customer service. All E/M services provided to a patient should be documented, regardless of whether the evaluation was performed as an independent service or in conjunction with other services rendered during a patient encounter.

Psychotherapy codes that include an E/M component are payable only to physicians, NPs and CNSs.

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Claim Submission

The CMS-1500 claim form (Health Insurance Claim Form) is the standard claim form used by a noninstitutional provider or supplier to bill MACs and DME MACs when a provider qualifies for a waiver from the ASCA requirement for electronic submission of claims.

NUCC is responsible for the maintenance of the CMS-1500 claim form. CMS and contractors do not provide the form to providers for claim submission.

Complete instructions for completion of the paper CMS-1500 claim form are provided in the Claim Form CMS-1500 instructions guide. Electronic claims may be filed for mental health services. The same information is reported regardless of the method of submission. Electronic claims are recognized as being more efficient, have faster processing times, and result in faster payment of Medicare claims to providers.

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CMS-1500 Claim Form Instructions

Procedure Coding

The CMS HCPCS is the coding system used by Medicare B nationwide and consists of two levels of codes and modifiers used by Medicare. Level I contains the AMA’s CPT codes which are numeric. Level II contains alpha-numeric codes primarily for items and nonphysician services not included in CPT. Level II codes are maintained jointly by CMS, the Blue Cross and Blue Shield Association and the Health Insurance Association of America.

Services provided to Medicare beneficiaries must be reported using the appropriate CPT or HCPCS code. It is not appropriate to report medical E/M procedure codes when psychotherapy is the reason for the encounter. If the medical E/M is the only service rendered on a given date of service, the appropriate E/M procedure code should be used.

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Units of Service

Mental health services are typically reported as one unit per session. Providers should choose the most appropriate mental health time-based code that reflects the actual service length provided. Indicate the number of units that are being provided on that date of service.

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Diagnosis Code Requirements

Report appropriate ICD-10-CM diagnosis codes in item 21 and reference the code in Item 24E of the CMS-1500 claim form or the electronic equivalent. The diagnosis code(s) chosen should accurately describe the patient’s illness, disease, signs or symptoms.

Codes must be used to their highest level of specificity. Follow instructions provided in the ICD-10-CM to avoid return or denial of claims for incorrect or invalid diagnosis coding.

Note: The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V) is not the HIPAA standard for diagnosis coding. Although the DSM-V includes diagnostic guidelines unlike the ICD-10, make sure you have the most current edition of the ICD-10 code book, which is updated on an annual basis, to avoid claim rejections and denials.

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LCDs and Articles Specific to Psychiatric Services

The underlying statutory requirement for all Medicare coverage is that it be medically “reasonable and necessary.” An LCD defines what is reasonable and necessary more explicitly if needed. NGS LCDs for psychiatric services are posted on our Medical Policies/LCDs web page.

  • LCD for Psychiatry and Psychology Services (L33632)
  • LCD for Psychiatric Partial Hospitalization Programs (L33626)
  • LCD for Psychiatric Inpatient Hospitalization (L33624)
  • Article for Health and Behavior Assessment/Intervention – Medical Policy Article (A52434))
  • Article for Psychological Services Coverage under the Incident to Provision for Physicians and Nonphysicians - Medical Policy Article (A52825)

Revised 3/19/2024