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Medical Policy                                    

Policy Num:       03.001.006
Policy Name:    PSYCHIATRY SERVICES
Policy ID:          [03.001.006][Ar L M+ P ][0.00.00]

Last Review:       November 14, 2019
Next Review:       N/A
Issue:                   11:19

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Related Policies:  None

  PSYCHIATRY SERVICES

Summary

Psychiatric evaluation

Psychiatric evaluation is the method by which the physician establishes a diagnosis of mental disorder and plan an intervention. In this assesment the physician investigates the symptoms of the person consulting and the factors that contribute to their emergence and maintenance, which can be briefly classified as psychological, social and somatic.

This evaluation of the disorders uses a multiaxial system with base in several axes (I-II-III-IV-V) each one of which refers to a different information domain and that can help the physician to raise the treatment and to foresee the clinical evolution. Namely the axes are:

• I- Clinical disorders
• II- Personality disorders
• III- General physical states
• IV- Psychosocial problems
• V- Global Function Evaluation

The central objective of a psychiatric evaluation should be:

• Establish a diagnosis
• Evaluate its severity and risk
• Evaluate the causes
• Establish a management plan
• Estimate a prognosis

The integrated psychiatric evaluation has the form of a semi-structured interview with the patient and often with their family and closest friends and complemented by a general medical history, past medical and psychiatric history, use of controlled substances history, psychosocial and sociocultural history, occupational and military history, legal history, systems review, physical and mental examination, basic laboratory analysis and chest X-rays.

Psychotherapy

Psychotherapy is the treatment of mental illness and conduct disorders where the physician and other qualified healthcare professionals using a specified therapeutic communication, attempt to relieve emotional disturbances, revert or change deviant behavior patterns and promote the development and growth of the personality.

Psychiatric documentation must include sufficient data justifying the medical necessity of the encounter, and enough information (history and examination) that leads to the diagnosis and treatment plan. The notes must show specific therapeutic interventions, how they are applied and treatment strategy. This documentation is essential to demonstrate the quality of service and good use.  The documentation of an iteration plan is indispensable with short, medium and long term objectives.

Evaluation and Management (E/M)

The evaluation and management (E/M) services are documented and coded according to the nature of the problem that they present and the key components in the service. These components include clinical history, physical examination, and medical decision making, considering the complexity and/or severity of the situation. They must contain sufficient information to justify medical necessity and what is appropriate of the treatment. It also includes counseling and coordination of care.

Notes of E/M must be kept separate from those of psychotherapy, but on the same record, for purposes of future audits.

Counseling

Counseling includes one or more of the following:

·       Discussion of studies results, impressions or recommendations of diagnostic studies

·       Prognosis

·       Risks and benefits of treatment options

·       Instructions related to the management of patient, and treatment options

·       Reduction of risk factors

·       Education of patient and his relatives

Crisis

Psychotherapy in a crisis situation is an urgent evaluation of the history that led to the situation, the mental state of the patient and the disposition of the case. The treatment includes psychotherapy, mobilization of resources necessary to resolve the crisis, restore the safety and implement the psychotherapeutic interventions necessary to minimize the potential psychological trauma. The problem usually represents a threat to the life and requires immediate attention.

Objective

The objective of this policy and its review is to determine if with aid of psychiatric management patients with schizophrenia, schizoaffective disorder, recurrent bipolar disorder, and chronic or recurrent psychotic depression improve their quality of life.

Policy Statements

 Psychiatric Services are medically necessary 

Policy Guidelines

Some psychiatric patients may require medical services on the same day that they receive psychotherapy services. Reportable medical services must be relevant, significant and separately identifiable. These services can be provided by the same psychiatrist or other medical personnel. These services must be reported using the codes of evaluation and management (E/M) that apply.  When reporting these medical services, the service notes of psychotherapy must be separately documented, for purposes of medical services auditing.

The codes of psychotherapy services 90832-90838 include the continuous evaluation and adjustment in the psychotherapeutic interventions and can include relatives or related in the treatment process.

The time of psychotherapy is that "face to face" service with the patient and/or relatives. The patient must be present in all or part of the time. For psychotherapy to the family, without the patient being present, the code to be used is 90846.

To inform the therapy time, choose the one that is closest to the intervention time (16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836 and 53 minutes or more to 90837 90838.) Times under 16 minutes should not be reported.

Psychotherapy offered to a patient in crisis must be reported using codes 90839 and 90840 and they should not be used in addition to the range of codes 90832-90838.

Code 90785 is an "add on" code to inform an interactive service that adds some complexity when codes 90832-90838 are billed. The time used by the physician to provide this service must be reflected in psychotherapy service time (90832, 90834, 90837) or psychotherapy time when it is billed with an evaluation and management (E/M) code, 90833, 90836 and 90838.

Benefit Application

BlueCard/National Account Issues

Background

Severe mental illness is a term used to characterize mental disorders with severe symptoms and behavioral impairment, pronounced disability in basic life skills, and a chronic or prolonged course of illness. Patients with these conditions typically have substantial impairments in personal, social and occupational functioning.

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

Regulatory Status

N/A

Rationale

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

Population Reference No. 1 Policy Statement

For individuals with severe mental illness ; with severe symptoms and behavioral impairment, pronounced disability in basic life skills, and a chronic or prolonged course of illness. Patients with these conditions typically have substantial impairments in personal, social and occupational functioning.

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

Applicable Modifiers

N/A

Policy History