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LCD ID Number: L33632 Status: A-Approved
LCD Title: Psychiatry and Psychology Services
Geographic Jurisdiction: Rhode Island Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
01/01/2024
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1862(a)(7) of Title XVIII of the Social Security Act excludes routine physical examination.
Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Code of Federal Regulations:
42 CFR, Section 410.27(f) indicates that “nonphysician practitioner” means a clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, clinical nurse specialist or certified nurse-midwife.
42 CFR, Section 410.42, describes limitations on coverage of certain services furnished to hospital outpatients.
42 CFR, Section 410.71, describes coverage of clinical psychologist services and supplies incident to a clinical psychologist
42 CFR, Section 410.73 – 410.76, describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.
42 CFR, Section 410.100 – 410.105, describes coverage, exclusions, and requirements for coverage of services furnished to an outpatient at a Comprehensive Outpatient Rehabilitation Facility (CORF).
CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6: 20.4.5 Coverage of Outpatient Diagnostic Services Furnished on or after January 1, 2011 20.4.6 Outpatient Diagnostic Services Under Arrangement 20.5.2 Coverage of Outpatient Therapeutic Services Incident to a Physicians Service Furnished on or after January 1, 2010 70.1 Outpatient Hospital Psychiatric Services (General) 70.2 Coverage Criteria for Outpatient Hospital Psychiatric Services CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12: 40.7 Social and/or Psychological Services CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1: 70.1 Consultations With a Beneficiary’s Family and Associates 130.1 Inpatient Hospital Stays for the Treatment of Alcoholism 130.2 Outpatient Hospital Services for Treatment of Alcoholism 130.3 Chemical Aversion Therapy for Treatment of Alcoholism 130.4 Electrical Aversion Therapy for Treatment of Alcoholism 130.5 Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic 130.6 Treatment of Drug Abuse (Chemical Dependency) 130.7 Withdrawal Treatments for Narcotic Addictions? 160.25 Multiple Electroconvulsive Therapy (MECT) CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1: 50.2.2 Frequency of Billing for Outpatient and Services to FIs CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12: 150 Clinical Social Worker (CSW) Services 160-160.1 Independent Psychologist Services 170-170.1 Clinical Psychologist Services
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