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Professional Services -

Psychiatric Services

The psychiatric services policies in this section apply to workers covered by the State Fund and self-insured employers (see WAC 296-21-270). Refer to the Medical Treatment Guideline for Psychiatric and Psychological Evaluation at
http://www.Lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/PsychEval.pdf for information on:

• Treatment guidelines
• Psychiatric conditions
• Reporting requirements
• Diagnosis of a psychiatric condition
• Identifying barriers that hinder recovery from an industrial injury
• Formulation of a psychiatric treatment plan
• Assessment of psychiatric treatment and recommendations

For information on psychiatric policies applicable to the Crime Victims‘ Compensation Program, refer to http://www.Lni.wa.gov/ClaimsIns/CrimeVictims/ProvResources/Default.asp and Chapter 296-31 WAC.

PROVIDERS OF PSYCHIATRIC SERVICES

Authorized psychiatric services must be performed by a psychiatrist (MD or DO), a psychiatric Advanced Registered Nurse Practitioner (ARNP), or a licensed clinical PhD psychologist (see WAC 296-21-270).

Licensed clinical psychologists and psychiatrists are paid at the same rate when performing the same service.

Psychiatric ARNPs are paid at 90% of the values listed in the fee schedule.

Psychiatric evaluation and treatment services provided by social workers, and other master‘s level counselors, are not covered even when delivered under the direct supervision of a clinical psychologist or a psychiatrist.

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.

PSYCHIATRISTS OR PSYCHIATRIC ARNPS AS ATTENDING PHYSICIANS

A psychiatrist or psychiatric ARNP can only be a worker‘s attending physician when the insurer has accepted a psychiatric condition and it is the only condition being treated. 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 may not rate permanent
partial disability.

Psychologists cannot be the attending provider and may not certify time loss from work or rate permanent partial disability per WAC 296-20-01002 (Doctor).

NONCOVERED AND BUNDLED PSYCHIATRIC SERVICES

The following services are not covered:

CPT® Code	CPT® Code
90802	90845
90810-90815	90846
90823-90829	90849
90857

The following services are bundled and are not payable separately:

CPT® Code

90885

90887

90889

PSYCHIATRIC CONSULTATIONS AND EVALUATIONS

Prior authorization is required for all psychiatric care referrals (see WAC 296-21-270). This requirement includes referrals for psychiatric consultations and evaluations.

When an authorized referral is made to a psychiatrist or psychiatric ARNP, they may bill either the E/M consultation codes or the 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.CPT® code 90801 is limited to 1 occurrence every 6 months, per patient, per provider.

Refer to WAC 296-20-045 and WAC 296-20-051 for more information on consultation requirements.

Telephone psychology services are not covered. Refer to the Teleconsultation and Other Telehealth Services section, page 41 for further details.

CASE MANAGEMENT SERVICES

Psychiatrists, psychiatric ARNPs, and clinical psychologists may only bill for case management services (telephone calls, team conferences and secure email) when providing consultation or evaluation.

For payment criteria and documentation requirements, see Case Management Services in the Evaluation and Management section, page 38.

INDIVIDUAL INSIGHT ORIENTED PSYCHOTHERAPY

Individual insight oriented psychotherapy services are divided into:

• Services with an E/M component, and
• Services without an E/M component.

Coverage of these services is different for psychiatrists and clinical psychologists.

Psychiatrists and psychiatric ARNPs may bill individual insight oriented psychotherapy codes (CPT® 90804-90809, 90816-90819, 90821-90822) either with or without an E/M component.

Psychotherapy with an E/M component may be billed when other services are conducted along with psychotherapy such as:

• Medical diagnostic evaluation,
• Drug management,
• Writing physician orders,
• Interpreting laboratory or other medical tests.

Clinical psychologists may bill only the individual insight oriented psychotherapy codes without an E/M component. They may not bill psychotherapy with an E/M component because medical diagnostic evaluation, drug management, writing physician orders and/or interpreting laboratory or other medical tests are outside the scope of a clinical psychologist‘s license.

Further explanation of this policy and CMS‘s response to public comments are published in Federal Register Volume 62 Number 211, issued on October 31, 1997. This is available on line at http://www.gpoaccess.gov/fr/index.html.

BILLING TIP: To report individual psychotherapy, use the time frames in the CPT® code descriptions for each unit of service. When billing these codes, do not bill more than 1 unit per day. When the time frame is exceeded for a specific code, bill the code with the next highest time frame.

USE OF CPT EVALUATION AND MANAGEMENT CODES FOR PSYCHIATRIC OFFICE VISITS

Psychologists may not bill the E/M codes for office visits.

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. The provider must submit documentation of the event and request a review before payment can be made.

PHARMACOLOGICAL EVALUATION AND MANAGEMENT

Pharmacological evaluation is payable only to psychiatrists and psychiatric ARNPs. If a pharmacological evaluation and psychotherapy are conducted on the same day, then the psychiatrist or psychiatric ARNP bills the appropriate psychotherapy code with an E/M component.

In this case, the psychiatrist or psychiatric ARNP must not bill the individual psychotherapy code and a separate E/M code (CPT® codes 99201-99215). Payment is not allowed for psychotherapy and pharmacological management services performed on the same day, by the same provider, for the same patient.

HCPCS code M0064 is not payable with:

• CPT® code 90862
• CPT® E/M office visit or
• Consultation codes (CPT® codes 99201-99215, 99241-99255).

HCPCS code M0064 is described "Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in treatment of mental psychoneurotic and personality disorders."

It is paid only if these described conditions are accepted or treatment is temporarily allowed by the insurer.

NEUROPSYCHOLOGICAL TESTING

The following codes may be used when performing neuropsychological evaluation. Reviewing records and/or writing/submitting a report is included in these codes and may not be billed separately.

CPT® Code	May be billed:
90801	Once every 6 months per patient per provider.
96101 and 96102	Up to a combined 4 hour maximum. In addition to CPT® codes 96118 and 96119.
96118 and 96119	Per hour up to a combined 12 hour maximum.

The psychologist is responsible to release test data to the insurer. 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, client/patient responses to test questions or stimuli, and psychologists' notes and recordings concerning client/patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data.

GROUP PSYCHOTHERAPY SERVICES

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. The insurer does not pay a group rate to providers who conduct psychotherapy exclusively for groups of workers.

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.

NARCOSYNTHESIS AND ELECTROCONVULSIVE THERAPY

CPT® codes 90865 and 90870 require prior authorization. Authorized services are payable only to psychiatrists.