Novitas Solutions Inc., the Medicare Administrative Contractor (MAC) A and B contractor for regions J-H and J-L on 06/25/2020 revised the Local Coverage Determination (LCD): Psychiatric Codes (L35101).
Highlights of Key LCD Guideline Topics
This LCD provides guidelines for several but not all psychiatric services. This LCD also specifies:
- the providers it applies to,
- the indications and services that are impacted by the policy.
Providers should contact their MAC for guidelines pertaining to specific psychiatric services or other billing, coding and coverage questions.
For the timely processing of claims, the LCD provides documentation guidelines on:
- General documentation requirements;
- Psychiatric Diagnostic Evaluation;
- Psychological and Neuropsychological Testing;
- Psychotherapy Services;
- Other Psychiatric and Psychological Services, and
- The medical necessity of all the services.
Please refer to the LCD for documentation requirements for your services and Products.
Main LCD Changes:
For dates of service on and after 07/01/2020:
- On 6.25.2020, the statement “Multiple family psychotherapy is directed to the effect of the patient’s condition on the family and does not meet Medicare’s standards of being part of the personal service to the patient. Therefore, this service is generally non-covered. If providers feel the multiple family psychotherapy services rendered meet the indications of psychotherapy outlined in this policy, they may follow the redetermination process” was removed. This revision was made in response to the Centers for Medicare and Medicaid Services direction.
- It is also noted that there were small formatting changes.
The LCD states that a “redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD”.
The Local Coverage Article (LCA) associated with this LCD has the billing codes that pertain to this LCD. The providers need to review both the LCD and the LCA and contact the MAC about their questions.
If the codes for the services rendered that are associated with your product or if your diagnostic tests meet the guidelines and indications of psychotherapy outlined in this policy, we can assist you with tracking the historical changes. If your providers disagree with the denials, we can assist with the redetermination process.
Why is it important to track policy changes?
- The coding, billing and documentation guidelines for your product are presented in the LCDs and the associated Articles and tracking their changes will help you assess billing, coding, or coverage impact on your Products.
- Providers rely heavily on payer policies for billing guidelines and coverage. Being familiar with the guidelines and following them will ensure clean claims and prevent denials and delays in coverage and payment.
- Providers need to be educated on the documentation guidelines to reduce delays in payment.
- It helps to track competitor Products entering the market as competitor products and their coding and billing guidelines are mentioned in coverage policies.
Why Partner with GIRS?
The GIRS Payer Advocacy Compass PAC® team has over 17 years of experience tracking payer policies and educating providers and stakeholders about changes to the policies to ensure coverage and reimbursement of our client’s medical technologies. We also have over 8 years of experience working with the American Psychiatric Association assisting with managed behavioral healthcare coding, coverage, and payment. We have operated medical technology hotlines to assist with the coding and billing of psychotropics and psychiatric services. Our work has enabled our clients to
- Analyze the impact of payer policy changes for our clients’ Products;
- comment on policy changes on time;
- correct mistakes in payer policies;
- clarify policy language for accounts;
- educate the sales force and accounts in new payer policy language;
- lay the foundation of customized payer advocacy strategies based on policy changes.
Please contact us at info@girsinc.com or avail of our Complimentary Review of your reimbursement needs at girsinc.com
About GIRS
For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.
Notice: CPT® is the trademark of the AMA. Reimbursement information is dynamic and is based on payer sources. Please contact us at girsinc.com for current information.