Chapter 25: Psychiatric Services
Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims
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Effective July 1, 2012 |
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Table of contents
Payment policies:
All psychiatric services
Case management services
Individual and group insight-oriented psychotherapy
Narcosynthesis and electroconvulsive therapy
Neuropsychological testing
Pharmacological evaluation and management
Psychiatric consultations and evaluations
More info:
Related topics
Definitions
Bundled:
A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services. Bundled codes are identified in the fee schedules.
Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules. This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.
Link: For the legal definition of “bundled,” see WAC 296-20-01002 .
Payment policy: All psychiatric services
Who the policies in this chapter apply to
The psychiatric services payment policies in this chapter apply to workers covered by the State Fund and self-insured employers.
The policies in this chapter don’t apply to crime victims.
Links: For more information on psychiatric services for State Fund and self-insured claims, see WAC 296-21-270. (Also, see “Additional information: Medical treatment guidelines for psychiatric conditions,” below.)
For information about psychiatric services’ policies for the Crime Victims’ Compensation Program, see www.Lni.wa.gov/ClaimsIns/CrimeVictims/ProvResources/Default.asp and WAC 296-31.
Who can be an attending provider and who can’t
Can be attending provider: Psychiatrists and psychiatric ARNPs
A psychiatrist or psychiatric ARNP can be a worker’s attending provider only when:
- The insurer has accepted a psychiatric condition, and
- It is the only condition being treated, and
A psychiatrist or psychiatric ARNP may certify a worker’s time loss from work if:
- A psychiatric condition has been allowed, and
- The psychiatric condition is the only condition still being treated.
A psychiatrist may also rate psychiatric permanent partial disability.
A psychiatric ARNP can’t rate permanent partial disability.
Can’t be attending provider: Psychologists
Psychologists can't be attending providers and can’t certify time loss from work or rate permanent partial disability.
Link: For more information on who can be an attending provider, see WAC 296-20-01002.
Payment rates for specific provider types
Licensed clinical psychologists and psychiatrists
Licensed clinical psychologists and psychiatrists are paid at the same rate when performing the same service.
Psychiatric ARNPs
Psychiatric ARNPs are paid at 90% of the values listed in L&I’s Professional Services Fee Schedule.
Link: The fee schedule is available at http://feeschedules.Lni.wa.gov.
Social workers and other master’s level counselors
Psychiatric evaluation and treatment services provided by social workers and other master’s level counselors aren’t covered even when delivered under the direct supervision of a clinical psychologist or a psychiatrist.
Who must perform these services to qualify for payment
Authorized psychiatric services must be performed by a:
- Psychiatrist (MD or DO),
- Psychiatric Advanced Registered Nurse Practitioner (ARNP), or
- Licensed clinical PhD or PsyD psychologist.
Psychological testing
Staff supervised by a psychiatrist, psychiatric ARNPs, or licensed clinical psychologist may administer psychological testing; however, the psychiatrist, or licensed clinical psychologist must:
- Interpret the testing, and
- Prepare the reports.
Services that aren’t covered
These services (CPT® billing codes) aren’t covered:
- 90802,
- 90810-90815,
- 90823-90829,
- 90857,
- 90845,
- 90846, and
- 90849.
Psychologists can’t bill the E/M codes for office visits.
Payment limits
These services (CPT® billing codes) are bundled and aren’t payable separately:
- 90885,
- 90887, and
- 90889.
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Psychiatrists and psychiatric ARNPs may only bill the E/M codes for office visits on the same day psychotherapy is provided if it’s medically necessary to provide an E/M service for a condition other than that for which psychotherapy has been authorized.
Note: The provider must submit documentation of the event and request a review before payment can be made.
Additional information: Medical treatment guidelines for psychiatric conditions
Link: The Medical Treatment Guideline for Psychiatric Conditions includes information on:
- Treatment guidelines,
- Psychiatric conditions,
- Purpose of the guideline,
- Authorization requirements,
- Elements of a comprehensive psychiatric plan,
- Diagnosis of a psychiatric condition,
- Identification of barriers to recovery from an industrial injury,
- Formulation of a psychiatric treatment plan,
- Assessment of psychiatric treatment and recommendations,
- Reporting requirements, and
- Billing Codes.
The guideline is available at www.Lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/PsychEval.pdf.
Payment policy: Case management services
Payment limits
Psychiatrists, psychiatric ARNPs, and clinical psychologists may only bill for case management services (telephone calls, team conferences, and secure e-mail) when providing consultation or evaluation.
Link: For more information about payment criteria and documentation requirements for these services, see the payment policy for “Case management services” in the Evaluation and Management chapter.
Payment policy: Individual and group insight-oriented psychotherapy
Prior authorization
Group psychotherapy
Group psychotherapy treatment is authorized on a case-by-case basis only.
If authorized, the worker may participate in group therapy as part of the individual treatment plan.
Requirements for billing
Individual psychotherapy services
To report individual psychotherapy:
- Don’t bill more than one unit per day, and
- Use the timeframes in the CPT® code descriptions for each unit of service, and
- When the timeframe is exceeded for a specific code, bill the code with the next highest timeframe.
Billable individual insight-oriented psychotherapy services are divided into services:
- With an E/M component, and
- Without an E/M component.
Note: Coverage of these services is different for psychiatrists and psychiatric ARNPs than it is for clinical psychologists (see below).
Psychiatrists and psychiatric ARNPs
Psychotherapy with an E/M component may be billed by psychiatrists and psychiatric ARNPs when other services are conducted along with psychotherapy such as:
- Medical diagnostic evaluation, or
- Drug management, or
- Writing physician orders, or
- Interpreting laboratory or other medical tests.
Psychiatrists and psychiatric ARNPs may bill the following individual insight-oriented psychotherapy CPT® billing codes either with or without an E/M component:
- 90804-90809,
- 90816-90819, and
- 90821-90822.
Clinical psychologists
Clinical psychologists may bill only the individual insight-oriented psychotherapy codes without an E/M component. They can’t bill psychotherapy with an E/M component because medical diagnostic evaluation, drug management, writing physician orders, and/or interpreting laboratory or other medical tests outside the scope of a clinical psychologist’s license.
Group psychotherapy services
If group psychotherapy is authorized and performed on the same day as individual insight-oriented psychotherapy (with or without an E/M component), both services may be billed, as long as they meet the CPT® definitions.
Note: The insurer doesn’t pay a group rate to providers who conduct psychotherapy exclusively for groups of workers.
Additional information: Policy background
Further explanation of this policy, as well as, CMS’s response to public comments is published in Federal Register Volume 62 Number 211, issued on October 31, 1997.
Link: This is available on line at www.gpoaccess.gov/fr/index.html .
Payment policy: Narcosynthesis and electroconvulsive therapy
Prior authorization
Narcosynthesis and electroconvulsive therapy require prior authorization.
Who must perform these services to qualify for payment
Authorized services are payable only to psychiatrists.
Services that can be billed
Use CPT® codes 90865 (narcosynthesis) and 90870 (electroconvulsive therapy).
Payment policy: Neuropsychological testing
What’s included in neuropsychological testing
Test data includes:
- The injured worker's test results,
- Raw test data,
- Records,
- Written/computer-generated reports,
- Global scores or individuals scale scores, and
- Test materials such as:
- Test protocols,
- Manuals,
- Test items,
- Scoring keys or algorithms, and
- Any other materials considered secure by the test developer or publisher.
The term test data also refers to:
- Raw and scaled scores,
- Patient responses to test questions or stimuli, and
- Psychologists' notes and recordings concerning patient statements and behavior during an examination.
Note: The psychologist is responsible for releasing test data to the insurer.
Services that can be billed
The following billing codes may be used when performing neuropsychological evaluation:
| If the CPT® code is… | Then it may be billed: |
| 90801 | Once every 6 months per patient per provider. |
| 96101 or 96102 | Up to a combined 4 hour maximum. In addition to CPT® codes 96118 and 96119. |
| 96118 or 96119 | Per hour, up to a combined 12 hour maximum. |
Note: Reviewing records and/or writing/submitting a report is included in these codes and can’t be billed separately.
Payment policy: Pharmacological evaluation and management
Who must perform these services to qualify for payment
Pharmacological evaluation is payable only to psychiatrists and psychiatric ARNPs.
Services that aren’t covered
HCPCS code M0064 isn't payable with:
- CPT® code 90862
- CPT® E/M office visit, or
- Consultation codes (CPT® codes 99201-99215, 99241-99255).
Requirements for billing
Services conducted on the same day
When a pharmacological evaluation is conducted on the same day as psychotherapy, then the psychiatrist or psychiatric ARNP bills one appropriate psychotherapy code that has an E/M component.
Note: Also see “Payment limits” for services conducted on the same day, below, as well as “Requirements for billing” under the payment policy for “Individual and group insight-oriented psychotherapy” earlier in this chapter.
Payment limits
Brief office visit (M0064)
HCPCS billing code M0064 is described as, “Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in treatment of mental psychoneurotic and personality disorders.” This code is paid only:
- If the conditions described by the code are accepted, or
- Treatment is temporarily allowed by the insurer.
Services conducted on the same day
Payment isn’t allowed for both psychotherapy and pharmacological management services when they are performed:
- On the same day,
- By the same provider,
- For the same patient.
When a pharmacological evaluation is conducted on the same day as psychotherapy, the psychiatrist or psychiatric ARNP:
- Can bill the individual psychotherapy code that has an E/M component, but
- Can’t bill a separate code for E/M (CPT® codes 99201-99215) at the same time.
Note: Also see “Requirements for billing,” above (in this same payment policy) as well as “Requirements for billing” under the payment policy for “Individual and group insight-oriented psychotherapy” earlier in this chapter.
Payment policy: Psychiatric consultations and evaluations
Links: For more information on consultations and consultation requirements, see WAC 296-20-045 and WAC 296-20-051 .
Prior authorization
Prior authorization is required for all psychiatric care referrals. This requirement includes referrals for psychiatric consultations and evaluations.
Services that can be billed
When an authorized referral is made to a psychiatrist or psychiatric ARNP, they may bill either the:
- E/M consultation codes, or
- Psychiatric diagnostic interview exam code.
When an authorized referral is made to a clinical psychologist for an evaluation, they may bill only CPT® code 90801 (Psychiatric diagnostic interview examination).
Services that aren’t covered
Telephone psychology services aren’t covered.
Links: For more information, see the payment policy for “Teleconsultation and other telehealth services” in the Evaluation and Management (E/M) Services chapter.
Payment limits
CPT® code 90801 is limited to one occurrence every six months, per patient, per provider.
Links: Related topics
| If you’re looking for more information about… | Then go here: |
| Administrative rules for attending providers |
Washington Administrative Code (WAC) 296-20-01002: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-01002 |
| Administrative rules for consultations and consultation requirements |
WAC 296-20-045: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-045 WAC 296-20-051: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-051 |
| Administrative rules for psychiatric services |
WAC 296-21-270: http://apps.leg.wa.gov/wac/default.aspx?cite=296-21-270 |
| Becoming an L&I provider | L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp |
| Billing instructions and forms | Chapter 2: Information for All Providers |
| Fee schedules for all healthcare facility services (including ASCs) |
L&I’s website: http://feeschedules.Lni.wa.gov |
| Medical treatment guideline for psychiatric conditions |
L&I’s website: www.Lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/PsychEval.pdf |
| Payment policies for case management services |
Chapter 10: Evaluation and Management (E/M) Services |
| Payment policies for teleconsultations and other telehealth services |
Chapter 10: Evaluation and Management (E/M) Services |
| Policy background for insight-oriented psychotherapy |
Federal Register Volume 62 Number 211 issued on October 31, 1997, available online: www.gpoaccess.gov/fr/index.html |
| Psychiatric services payment policies for crime victims |
L&I’s website: www.Lni.wa.gov/ClaimsIns/CrimeVictims/ProvResources/Default.asp WAC 296-31: http://apps.leg.wa.gov/wac/default.aspx?cite=296-31 |
Need more help? Call L&I’s Provider Hotline at 1-800-848-0811.
CPT® codes and descriptions only are © 2011 American Medical Association
