Site Alert

Most of our online systems will be unavailable from 6 a.m. to 2 p.m. on Saturday, November 22, 2014, for scheduled system upgrades. We apologize for any inconvenience.

Chapter 25: Psychiatric Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



Go Back Return to Billing & Payment Policies


Go Back Return to Fee Schedule Lookup

Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

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.

 


If you’re looking for more information about… Then go here:
Administrative rules
for attending providers
Washington Administrative Code (WAC) 296-20-01002:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-01002
Administrative rules for
consultations and consultation
requirements
WAC 296-20-045:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-045
WAC 296-20-051:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-051
Administrative rules for
psychiatric services
WAC 296-21-270:
http://app.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://app.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

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.