90836
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.17
Facility
$83.17
Non-Facility
$103.21
Documentation Required
- Medical record must document that the billing provider personally evaluated the patient and initiated the course of treatment prior to incident-to psychological services being provided.
- Maintain documentation of practitioner credentials, state licensure or authorization, and evidence that the practitioner is acting within the state-authorized scope of practice.
- Document the supervisory arrangement showing general physician supervision (physician's overall direction/control) and the physician's responsibility for training and maintenance of equipment/supplies.
- If the physician's office is located in an institution, document that auxiliary personnel are members of the physician's office staff and that supplies are expenses of the physician's office.
Key Coverage Criteria
- Psychological services may be furnished 'incident to' a physician's professional services only after the billing provider personally evaluates the patient and initiates the course of treatment; trained therapists may then provide services under the billing provider's general supervision.
- Psychological services incident to are covered when performed by one of the listed practitioner types—Doctorate or Masters Clinical Psychologist, Clinical Social Worker, Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Marriage and Family Therapist (MFT), or Mental Health Counselor (MHC)—each acting within their state-authorized scope of clinical practice and providing services represented by the specified CPT/HCPCS codes.
- General physician supervision is required for incident-to psychological services (physician need not be present but retains overall direction/control and responsibility for training and equipment/supplies).
- When a physician's office is located within an institution, incident-to coverage applies only if the auxiliary personnel are members of the physician's office staff, the cost of supplies is an expense to the physician's office, and services are generally supervised by the physician.
- Partial Hospitalization Program services that meet the coverage criteria of Local Coverage Determination L37633 are considered covered.
- Patient requires active psychiatric partial hospitalization (PHP) with an individualized written plan of care developed by a physician in consultation with appropriate staff and a multidisciplinary team.
20 Active Policies
A57480 — Billing and Coding: Psychiatry and Psychology Services
J05
L34616 — Psychiatry and Psychology Services
J05
A56850 — Billing and Coding: Psychiatric Partial Hospitalization Programs
J06
L33626 — Psychiatric Partial Hospitalization Programs
J06
L33632
Related Codes
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