Section I: General Clinical Psychiatric Diagnostic or Evaluative
Interview Procedures:
Description: A psychiatric diagnostic interview examination (90801)
includes a history, mental status exam, and a disposition, as well as
ordering and medical interpretation of laboratory or other medical
diagnostic studies. The diagnostic interview may include
communication with family or other sources, and in certain
circumstances, other informants will be seen in lieu of the patient. The
psychiatrist obtains a complete medical and psychiatric history from
the patient and/or family and establishes a tentative diagnosis. The
patient's capacity to work psychotherapeutically is also evaluated to
determine how willing he or she is to work toward a positive solution
to the problem. The patient's condition determines the extent of the
mental status examination during the diagnostic interview. The
psychiatrist is looking for symptoms of psychopathology in the
patient's general appearance, attitude toward the examiner, and
overall behavior. In addition, the speech-language and stream of talk,
emotional reaction and mood, perception and thought content, and
cognition may be evaluated.
An evaluation and management (E/M) service may be substituted for
the initial interview procedure, including consultation codes
(CPT99241-99255), provided all required elements of the E/M service
billed are fulfilled. Consultation services require, in addition to the
interview and examination, providing a written opinion and/or advice.
They do not include psychiatric treatment, though such treatment may
be initiated on the same day as the consultation.
A psychiatric diagnostic interview examination is usually covered once,
when a provider first sees a patient for a suspected or diagnosed
psychiatric illness. It may be utilized again for the same patient if a
new episode of illness occurs or is thought to have occurred, or on
admission, or re-admission to inpatient status due to complications of
the underlying condition. If the provider is unable to perform the
psychiatric diagnostic interview examination at the initial encounter
because of the patient's mental or physical condition, a code should be
selected for the initial encounter based specifically on what
services/procedures the psychiatrist did perform or provide. If, after
completing an assessment it is concluded that no mental illness is
present, the visit may be coded with ICD-9-CM V71.09 (Observation
for suspected mental condition - Other suspected mental condition).
“Incident To” Services:
“Incident to a physician’s professional services means that the services or supplies
are furnished as an integral, although incidental, part of the physician’s personal
professional services in the course of diagnosis or treatment of an injury or illness.”
[CMS Medicare Benefit Policy Manual, Chapter 15, Section 60.1 (MCM 2050.1).]
The “incident to” provision also applies to coverage for psychological services
furnished “incident to” the professional services of certain non-physician practitioners
(Clinical Psychologists, Clinical Nurse Specialists, and Nurse Practitioners). The
training requirements and state licensure or authorization of individuals who perform
psychological services are intended to ensure an adequate level of expertise in the
cognitive skills required for the performance of diagnostic and therapeutic
psychological services. Therefore, only the types of individuals listed below are
considered qualified to perform medically necessary psychological services as
“incident to” services. Delegation of diagnostic and therapeutic psychological services
to personnel not performing within the Scope of Practice as authorized by state law,
under the “incident to” provision, would bypass the safeguards afforded by
professional credentialing and state licensure requirements. Such delegated services
under the “incident to” provision would be inappropriate, unreasonable and medically
unnecessary, and therefore, not covered by Medicare.
Only the following types of individuals, when they are performing within their
authorized scope of clinical practice under the state law where the service is
performed, are qualified to perform the indicated diagnostic and/or therapeutic
psychological services under the “incident to” provision:
1. Doctorate level psychologists (Specialty Code 68): 90801, 90802, 90804, 90806,
90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90845,
90846, 90847, 90849, 90853, 90857, 90880, 90899
2. Doctorate or Masters level social workers (Specialty Code 80): 90801, 90802,
90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826,
90828, 90846, 90847, 90849, 90853, 90857, 90899
3. Nurse Practitioners (NPs) (Specialty Code 50): 90801, 90802, 90804, 90806,
90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90846,
90847, 90849, 90853, 90857, 90880, 90899, (Also, if authorized by the state to
prescribe medication: 90862, 90805, 90807, 90809, 90811, 90813, 90815, 90817,
90819, 90822, 90824, 90827, 90829)
4. Clinical Nurse Specialists (CNSs) (Specialty Code 89): 90801, 90802, 90804,
90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828,
90846, 90847, 90849, 90853, 90857, 90880, 90899, (Also, if authorized by the
state to prescribe medication: 90862, 90805, 90807, 90809, 90811, 90813, 90815,
90817, 90819, 90822, 90824, 90827, 90829)
5. Other psychotherapists licensed by the state to perform psychotherapy, e.g.,
licensed marriage and family therapists: 90804, 90806, 90808, 90810, 90812,
90814, 90846, 90847, 90849, 90857, 90880, 90899)
The psychological services referenced in the above CPT codes may be delegated only
to employees who qualify for one of the five categories of individuals listed above.
For example, a psychiatrist may hire a social worker to perform services “incident
to,” but the services the social worker may perform must be limited to the services
designated by the CPT codes listed in number 2 above. Individuals who are
performing services “incident to” a qualified Medicare practitioner are not required to
be separately enrolled as an independent practitioner in Medicare. Also, it is not
appropriate for the billing provider to hire and supervise a professional whose scope
of practice is outside the provider’s own scope of practice as authorized under State
law, or whose professional qualifications exceed those of the “supervising” provider.
For example, a certified nurse midwife (CNMW) may not hire a psychologist and bill
for that psychologist’s services under the “incident to” provision, because a
psychologist’s services are not integral to a CNMW’s personal professional services
and are not regularly included in the CNMW’s bill. Even though sections
1861(s)(2)(L) and 1861(gg) of the Social Security Act authorize coverage for
services furnished “incident to” a CNMW’s services, psychological services are not
commonly furnished in CNMW’s offices nor within their scope of practice. Similarly,
even though section 1861(s)(2)(K)(iv) authorizes coverage for services furnished
“incident to” a physician assistant’s services, a physician assistant would not be
qualified to supervise psychological services performed by the types of individuals
listed above.