April 26, 2021
Notification of Service Specific Post Payment Review for Psychotherapy: Codes 90832, 90834, 90837
Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with post payment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.
The goal of CGS's Medical Review (MR) program is to reduce errors through claims reviews and education on Medicare's coverage, coding, payment and billing policies. To achieve this goal, we conduct data analysis to identify provider billing services of CPT/HCPCS codes that pose the greatest risk to the Medicare program.
The reviews will involve providers billing service codes 90832 (psychotherapy, 30 minutes with patient), 90834 (psychotherapy, 45 minutes with patient), and 90837 (psychotherapy, 60 minutes with patient). Documentation will be reviewed for compliance with Medicare rules and regulations such as: medical necessity; required components and signatures; deliverance of the service; as well as correct coding and billing per medical necessity.
Additional Documentation Request (ADR) letters will be sent. Please submit requested documentation within 45 days of receipt of the ADR letter. Please include a copy of your ADR letter and claim cover sheet with each claim documentation submission. Failure to respond by the 45th day will result in denial for non-response and recoupment of dollars paid in error.
Documentation Necessary to Process the Claim
We expect the documentation submitted with each ADR letter to include a copy of the following legible and signed documentation from each patient's medical record:
- Beneficiary's name
- Date of service (DOS)
- Documentation of time
- Individualized Treatment plan:
- Type
- Amount
- Frequency
- Duration of services to be furnished
- Diagnoses
- Anticipated goals
- Reasonable expectation of improvement or reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate.
- Treatment note:
- supporting face to face visit with the patient
- supporting therapeutic maneuvers; communication attempts supportive or interpretive interactions to produce a therapeutic change
- that summarizes
- Diagnosis
- Symptoms
- Functional status
- Mental status examination
- Treatment plan
- Prognosis
- Progress
- Name, signature and credential of the person performing the service
- Periodic summary of
- Goals
- Progress towards goals
- Updated treatment plan if applicable
- Appropriate signatures
- Signature and credentials of person performing the service
- Amendments/corrections/delayed entries are properly identified
- Amendments/corrections/delayed entries are initialed and dated by author
For more information regarding signature requirements, please visit our website.
Guidelines regarding signature requirements are located in the CMS Internet-only Manual (IOM) Publication (Pub.) 100-08, Chapter 3, Section 3.3.2.4, “Signature Requirements.” Information is also available in CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes.”
Notification of Results
Providers will be notified via results letter for denied claims with an estimated overpayment. You will receive a letter from Overpayment Recovery with the final overpayment amount. If you disagree with the decision, you may request a redetermination within 120 days of the date of your demand letter.
References:
- Local Coverage Determination (LCD): Outpatient Psychiatry and Psychology Services (L34353)
- CMS Internet-only Manual (IOM) Publication (Pub.) 100-02, Chapter 6, Sections 70.1 & 70.2; Chapter 15, Sections 80.2, 160, 170
- CMS IOM Pub. 100-03, Chapter 1, Section 70.1
- CMS IOM Pub. 100-04, Chapter 12, Sections 150, 160-160.1, 170-170.1
- CGS Outpatient Psychiatry & Psychology Services Fact Sheet
- CGS MR Activities