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Contractor Information

Contractor Name: First Coast Service Options, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 09201 Contractor Type: MAC A

LCD Information

LCD ID Number: L33252 Status: A-Approved LCD Title: Psychiatric Diagnostic Evaluation and Psychotherapy Services Geographic Jurisdiction: Puerto Rico, Virgin Islands Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 07/01/2020 Revision End Date: CMS National Coverage Policy: This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Psychiatric Diagnostic Evaluation and Psychotherapy Services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Psychiatric Diagnostic Evaluation and Psychotherapy Services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. Internet Only Manual (IOM) Citations: CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Section 30 Outpatient Mental Health Treatment Limitation CMS IOM Publication 100-02, Medicare Claims Processing Manual, Chapter 15, Section 40.4 Definition of Physician/Practitioner, Section 60 Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service, and Section 160 Clinical Psychologist Services CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 120 Nurse Practitioner(NP) And Clinical Nurse Specialist (CNS) Services Payment Methodology, Section 120.2 Outpatient Mental Health Treatment Limitation, Section 120.3 NP and CNS Billing to the A/B MAC (b), Section 160 Independent Psychologist Services, Section 170 Clinical Psychologist Services, Section 210 Outpatient Mental Health Treatment Limitation, and Section 210.1 Application of the Limitation CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.6 Psychotherapy Notes Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD Social Security Act (Title XVIII) Standard References:   Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.  Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.  Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.  Federal Register References:  Code of Federal Regulations (CFR), Title 45, Volume 1, Subpart E Privacy of Individually Identifiable Health Information, Part 164.501 Definitions. Sorry, you need to login or register to view additional sections of this Medicare policy. *