01-106 OIG Psychotherapy Services Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting a post-payment review of claims for Medicare Part B billed on dates of service from January 1, 2023, through May 11, 2023. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers or suppliers may wish to consult when submitting claims.
The codes used to bill psychotherapy services are time-based codes. Start and stop times or total times must be documented for Current Procedural Terminology (CPT) codes 90832 (Psychotherapy 30 minutes); 90834 (Psychotherapy 45 minutes); and 90837 (Psychotherapy 1 hour). For psychotherapy services performed with an Evaluation and Management (E&M) service, the psychotherapy time may not be continuous in a combined psychotherapy with an E&M service. Therefore, documentation must support the start and stop times, or total time of the psychotherapy with an E&M service and documentation must support the start and stop times, or total time devoted to psychotherapy. Psychotherapy of less than 16 minutes duration should not be reported.
Telemedicine is defined as the exchange of medical information from one site to another through electronic communication, to improve a beneficiary’s health. An example of telemedicine services includes telehealth which is the use of interactive audio and video (two-way) telecommunications system allowing real-time communication between the originating (patient location) and distant site (provider location) to provide approved telehealth services for Medicare beneficiaries.
The Office of Inspector General (OIG), published a report in May 2023 (A-09-21-03021) titled, Medicare Improperly Paid Providers for Psychotherapy Services, Including Those Provided Via Telehealth During the First Year of The Covid-19 Public Health Emergency (PHE).” Prior OIG audits of four psychotherapy providers identified high improper payment rates for psychotherapy services furnished before the PHE.
Reason for Review
As a result of the OIG report, CMS tasked the SMRC to conduct data analysis and perform medical review on psychotherapy services, including services provided via telehealth, to verify that the services are documented and billed in accordance with Medicare requirements.
The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
|90832||Psychotherapy 30 minutes|
|90833||Psychotherapy 30 minutes with Evaluation and Management|
|90834||Psychotherapy 45 minutes|
|90836||Psychotherapy 45 minutes with Evaluation and Management|
|90837||Psychotherapy 60 minutes|
|90838||Psychotherapy 60 minutes with Evaluation and Management|
Access related project details below.
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Documentation to support the code(s) and modifier(s) billed.
- Psychiatric diagnostic evaluation or psychotherapy face-to-face encounter, including the time spent in the psychotherapy encounter.
- Initial psychiatric/psychological evaluation/mental status exam.
- Individualized treatment plan for psychiatric services with updates.
- Psychiatric evaluation and all behavioral/psychological/psychiatric tests that have been performed.
- Documentation to support consent for telehealth visit.
- Documentation to support the beneficiary initiated the telehealth visit.
- Documentation to support the originating site billed.
- Documentation to support Local Coverage Determination (LCD) and/or Policy Article.
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services).
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
- Any other supporting/pertinent documentation.
- If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
- PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.
Social Security Act (SSA), Title XI
- § 1135. Authority to Waive Requirements During National Emergencies.
Social Security Act (SSA), Title XVIII
- § 1815(a). Providers must furnish information.
- § 1833(e). Payment of Benefits.
- § 1834(m). Payment for Telehealth Services.
- § 1842(p)(4). Provisions Relating to the Administration of Part B.
- § 1862(a)(1)(A). Exclusion from Coverage and Medicare as a Secondary Payer.
- § 1877(g). Blanket Waivers of Section 1877 (G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency.
- § 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
Title 42 of the Code of Federal Regulations (CFR)
- § 410.78. Telehealth Services.
- § 411.15(k)(1). Particular Services Excluded from Coverage.
- § 414.65. Payment for Telehealth Services.
- §§ 424.5 and 424.5(a)(6). Basic Conditions and Sufficient Information.
- CMS 1744-IFC. Medicare and Medicaid Programs, Policy, and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). Telehealth Services During Certain Emergency Periods.
- Public Health Service Act, 2021, Section 319(e) Telehealth Enhancements for Emergency Response.
- Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments.
- Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 31, 2020.
- Federal Register, Vol. 77, No. 222. November 6, 2012. CMS-1590-FC. Effective 1/1/2013.
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02
- Chapter (Ch.) 15, § 270. Telehealth Services.
- Ch. 16. General Exclusions from Coverage.
IOM, Medicare Claims Processing Manual, Publication (MCPM) 100-04
- Ch. 12, § 150. Clinical Social Worker (CSW) Services.
- Ch. 12, § 160. Independent Psychologist Services.
- Ch. 12, § 170. Clinical Psychologist Services.
- Ch. 12, § 190. Medicare Payment for Telehealth Services.
- Ch. 23, § 20.9. National Correct Coding Initiative (NCCI).
IOM, Medicare Program Integrity Manual, Publication (MPIM) 100-08
- Ch. 3, § 22.214.171.124. Coverage Determinations.
- Ch. 3, § 126.96.36.199. Reasonable and Necessary Criteria.
- Ch. 3, § 188.8.131.52. Limitation of Liability Determinations.
- Ch. 3, § 184.108.40.206. Signature Requirements.
- Ch. 13, § 13.5.4. Reasonable and Necessary Provisions in LCDs.
- Ch. 3, § 220.127.116.11. Coding Determination.
- Ch. 3, § 18.104.22.168. Denial Types.
- Ch 3, § 22.214.171.124. Psychotherapy Notes.
- Ch. 3, § 126.96.36.199. No response of Insufficient Response to Additional Documentation Requests.
CMS Coding Policies
- National Correct Coding Initiative Coding Policy Manual for Medicare Services.
Technical Direction Letter (TDL)
- TDL-210317. Medical Review of Timed Codes.
Local Coverage Determination (LCD)
- L33252: Psychiatric Diagnostic Evaluation and Psychotherapy Services.
- L33632: Psychiatry and Psychology Services.
- L34353: Outpatient Psychiatry and Psychology Services.
- L34616: Psychiatry and Psychology Services.
- L35101: Psychiatric Codes.
Local Coverage Article (LCA)
- A56937: Billing and coding: Psychiatry and Psychology Services.
- A57065: Billing and Coding: Outpatient Psychiatry and Psychology Services.
- A57130: Billing and Coding: Psychiatric Codes.
- A57480: Billing and Coding: Psychiatry and Psychology Services.
- A57520: Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services.
- American Medical Association, Current Procedural Terminology (CPT) Manual, Professional Edition (2020).
- Medicare Learning Network (MLN) 2020-11-12-MLNC, COVID 19: Non-Physician Practitioner Billing Audio Services.
- Medicare Leaning Network (MLN), MM12427 New/Modifications to the Place of Service (POS) Codes for Telehealth. Effective January 1, 2022.
Last Updated Sep 22, 2023