This Local Coverage Determination (LCD) supplements but does not supersede, modify, or replace any existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for outpatient psychotherapy services. The federal statutes and Medicare regulations are lengthy and will not be repeated in this LCD. All providers who report service covered under this LCD must follow all existing laws, regulations and standards for Medicare payment and must properly submit valid claims for these services.
Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment only for services deemed reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, 1862(a)(7) excludes routine physical exams.
45 CFR, §164.501 Definitions
42 CFR, §410.71 Clinical psychologist services and services and supplies incident to clinical psychologist services
42 CFR, §410.73-410.76 Coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists
42 CFR §410.100-410.105 Coverage, exclusions, requirements for coverage of services furnished to an outpatient in a Comprehensive Outpatient Rehabilitation Facility (CORF).
CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, §30 Outpatient Mental Health Treatment Limitation
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.5 Outpatient Therapeutic Services, §70.1 Outpatient Hospital Psychiatric Services (General), §70.2 Coverage Criteria for Outpatient Hospital Psychiatric Services
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §40.7 Social and/or Psychological Services
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §160 Clinical Psychologist Services
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §70.1, Consultations With a Beneficiary’s Family and Associates
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §120.2 Outpatient Mental Health Treatment Limitation, §150 Clinical Social Worker (CSW) Services, §160, Independent Psychologist Services, §160.1 Payment, §170 Clinical Psychologist Services, §170.1 Payment, §210 Outpatient Mental Health Treatment Limitation
CMS Internet-Only Manual, Pub. 100-08 Medicare Program Integrity Manual, Chapter 3, §3.3.2.6 Psychotherapy Notes
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