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Medical Policy

Policy Num:       03.001.001
Policy Name:   Psycotheraphy
Policy ID:          [3.001.001][Ac L M + P ][0.00.00]

Last Review:      November 11,2020
Next Review:      ARCHIVED
Issue:                  11:2020

Related Policies:

None

Psycotheraphy

Summary

The description of codes 90785-90840 contemplates the treatment of a mental condition or behavioral disturbance. In these the clinician establishes a professional contact (face to face) through therapeutic communication with the patient. The purpose is to alleviate, change or reverse patterns of misbehavior-adapted and encourage the growth and development of personality.

Objective

Cognitive and behavior therapies (CBT) have been shown to work in broad range of disorders and for many problems in living not typically classified as psychiatric disorders in both children and adults.

Policy Statements

The patient receives medical evaluation and management services. These services involve a variety of unique, medical management responsibilities for psychiatric patients, such as:

• medical evaluations

(Eg tests for assessing comorbidity of mental condition, drug interaction and physical examination).

• medication management, when indicated.

• medical orders

• interpretation of laboratories or

• any other diagnostic study and

• observation

This visit must be clearly documented in the file.

90785

Interactive: this concept includes and recognizes the effort required for situations where there is: difficulty of communication for different types of patients and situations that represent important factors that complicate and increase the intensity of the primary psychiatric process.

90791

This service is paid once every three years, if the patient has not had

other services with the provider or another participant of the group during that period of time.

During the initial examination code 90791; the provider conducts an interview with the patient to acquire a complete medical history (including past, family, social) and psychiatric history, mental status, and disposition to obtain a diagnosable disorder. In some cases, the initial diagnostic interview (code 90791) may include: communication with family or other sources, and in certain circumstances, it may also be necessary that other informants will be seen in place of the patient. The extent of mental status evaluation depends on the patient's condition. There are some symptoms of psychopathology that the provider will study to determine the initial treatment plan, such as, but not limited to, the patient's appearance.

90792

This service is paid once a year.

The code 90792; in addition to including (such as code 90791) history and mental status of review and review and / or diagnostic study orders as necessary, recommendations (includes communications with family or other sources). It also includes the psychiatric examination (CMS), prescription of medications when appropriate and any order or reading of laboratory tests.

It is paid more than once per patient when an evaluation is carried out separating a different diagnosis with the patient and other informants.

It is not paid on the same day as a psychotherapy, nor on the same day as an evaluation and management (E / M codes)

When reporting the add-on codes, the real time spent in the meeting must be taken into consideration. Example:

- from 16 to 35 minutes the codes to report are 90832-90833

- from 38-52 minutes the codes to report are 90834-90836

- of 53 minutes or more the codes to report are 90837 or 90838 according to

Apply

When an evaluation and management (E / M) is carried out in conjunction with the same-day psychotherapy by the same physician (90833, 90836, 90838), the evaluation and management service (E / M) documentation must identify a significant encounter separate from psychotherapy. Please refer to the assessment and management (E / M) criteria reported in the Evaluation and Management Section of the Triple S-Health Participant Payment Policy Manual. Clear documentation of assessment and management services is recommended in a separate section within the patient's record as these services are auditable

Policy Guidelines

Specifics of what cognitive and behavioral therapies should include and time dedicated to the patient are stated above, with emphasis on goals and periodic assessment of objectives achieved during therapy.

Benefit Application

BlueCard/National Account Issues

N/A

Background

Most people, at one time or another, need some help. For some, talking with a therapist helps them understand ways to improve their life. Sometimes people seek therapy at the advice of a physician or a health agency. Sometimes it's overwhelming life stress or a particular crisis that causes a person to decide to go to therapy. And many times people enter therapy to gain insight and acceptance about themselves and to achieve personal growth. Psychotherapy is for anyone who is unhappy with the way he or she acts or feels, and wants to change.

Behavioral Therapies

Behaviorally oriented therapists practice a particular kind of therapy known as behavior therapy. Behavior therapy involves the application of findings from behavioral science research to help individuals change in the way they would like to change. Behavior therapy places a strong emphasis on the principles of learning and on how faulty learning may cause problems in a person's life. There is also an emphasis in behavior therapy on checking up on how effective the therapy is by monitoring and evaluating the client's progress. Most behaviorally oriented therapists believe that the current environment is most important in affecting the person's present behavior. The procedures used by behavior therapists are generally intended to improve the individual's self-control by expanding the person's skills and abilities. Almost all behavior therapists assign homework and the practice of new behaviors as part of their therapy.

Another type of behavior therapy is cognitive behavior therapy or cognitive therapy. Cognitive therapists believe that many problems stem from irrational and dysfunctional thoughts, ideas, and beliefs, and that these thoughts may affect a person's behavior and emotions. The goal of cognitive behavioral therapy is to modify a client's way of thinking so that a change in behavior and emotions can occur.

 CBT or Medication for Non-psychotic and Psychotic Disorders

Non-psychotic Disorders (e.g., Disorders NOT involving a loss of contact with reality, such as schizophrenic or manic disorders)

·         As a general rule, findings suggest that CBT can do anything that medications can do in the treatment of the nonpsychotic disorders and it can do so without causing problematic side effects. CBT also can address symptoms on a more enduring basis.

·         Research suggests that medications often work but they do so only for so long as you keep taking them, whereas CBT may reduce risk for subsequent symptom return long after treatment is over.

·         Psychiatric medications typically treat the symptoms but do not cure the disorders, whereas you can learn things in CBT that may reduce your risk of the disorder coming back.

·         People with more severe symptoms may benefit from adding medications, particularly among disorders like depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder. For the less severe instances of these disorders the evidence for CBT is at least as strong as that for medications and for some disorders it is even stronger.

·         Medications tend to work a little faster than CBT (by a matter of weeks) and there are sometimes benefits from using the two in combination or in sequence.

·         CBT represents a viable alternative to medications for people with nonpsychotic disorders in most instances. However, there are indications that taking medications may undermine the enduring effects of CBT in some patients.

Psychotic Disorders

A different rule applies for the psychotic disorders (those involving a loss of contact with reality like schizophrenia or mania). For those disorders, medication treatment has the best empirical support and represents the current standard of treatment.

CBT and certain family focused interventions often can play a useful adjunctive role in these disorders but they should not be used instead of medications.

Regulatory Status

This policy also applies to telemedicine psychotherapy services with place of service 2

Rationale

N/A

Population Reference No. 1 Policy Statement

Individuals with psychiatric disorders. Findings regarding the effectiveness of psychotherapy as an alternative to medications is mostly available for CBT therapy. There are many other approaches to psychotherapy; data indicating whether these other approaches are effective are still emerging

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.     BCBSND Bulletin 300 December 2008 

2. Current Procedural Terminology (American Medical Association 2013) 

3. Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database Syst Rev 2010; :CD007906

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013

5. The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL. (Ed), American Psychiatric Publishing, Inc, Washington, DC 2011

6. Saravay SM. Interventions, outcomes, and costs. In: Psychosomatic Medicine, Blumenfield M, Strain JJ. (Eds), Lippincott Williams & Wilkins, Philadelphia, PA 2006. p.867

Codes

Appplicable Modifiers

Some modifiers

Policy History