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Print-Friendly VersionMedicare Mental HealthCPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved.Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. ApplicableFARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/orrelated components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. TheAMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for datacontained or not contained herein.Page 1 of 33MLN1986542 June 2021
Medicare Mental HealthMLN BookletTable of ContentsWhat’s Changed? . 3Introduction. 4Covered Medicare Fee-for-Service Mental Health Services . 4Prescription Drug Coverage . 7Medicare Advantage Organizations . 7Non-Covered Medicare Fee-for-Service Mental Health Services . 7Eligible Professionals . 7Provider Information . 8Table 1. Psychiatrist . 8Table 2. Clinical Psychologist (CP) . 9Table 3. Clinical Social Worker (CSW) . 10Table 4. Clinical Nurse Specialist (CNS) .11Table 5. Nurse Practitioner (NP) . 12Table 6. Physician Assistant (PA) . 13Table 7. Certified Nurse-Midwife (CNM). 14Table 8. Independently Practicing Psychologist (IPP) . 15Incident to Provision . 16Commonly Used CPT Codes . 16Table 9. Eligible Professionals Commonly Used CPT Codes . 16National Correct Coding Initiative (NCCI) . 20Outpatient Psychiatric Hospital Services . 20Partial Hospitalization Program (PHP) . 21Community Mental Health Center (CMHC) . 23Behavioral Health Integration (BHI) Services. 23Medical Records Checklist: Outpatient Psychiatric Services . 24Acute Care Hospital . 27Inpatient Psychiatric Facility (IPF) Services . 27Medical Records Requirements . 27Medical Records Checklist: Inpatient Psychiatric Services . 28Coverage Period . 32Same Day Billing Guidelines . 32Resources . 33Page 2 of 33MLN1986542 June 2021
Medicare Mental HealthWhat’s Changed? Clarified NP coverage requirements in Table 5You’ll find substantive content updates in dark red font.Page 3 of 33MLN1986542 June 2021MLN Booklet
Medicare Mental HealthMLN BookletIntroductionThis booklet offers a comprehensive review of Medicare covered behavioral health services. Behavioralhealth services, typically referred to as mental health services and includes substance abuse, affectsa patient’s overall well-being. It’s important to understand Medicare coverage of these services. Thisbooklet includes information on covered and non-covered services, eligible providers, MedicareAdvantage and Medicare drug plan coverage, as well as medical record documentation and coding.Covered Medicare Fee-for-Service Mental Health ServicesMedicare may cover these services to support behavioral health and wellness: Alcohol misuse screening and counseling for adults who use alcohol but aren’t dependent; if youdetect misuse, Medicare covers up to 4 brief face-to-face counseling sessions per year if patient isalert and competent during counseling Alcohol treatment, detoxification, outpatient hospital treatment, and rehabilitative servicesincluding inpatient hospital stays Annual Wellness Visit (AWV) to develop or update a personalized prevention plan including ahealth risk assessment and a depression screening Advance care planning to discuss the patient’s health care wishes if they aren’t able to makedecisions about their care, as part of the AWV, or as a separate Part B service Behavioral Health Integration (BHI) by clinical staff to assess, monitor, and plan care Biofeedback therapy, a non-drug treatment where patients learn to control bodily responses likeheart rate and muscle tension Bundled Payments for Opioid Use Disorder (OUD) are payments for OUD management andcounseling, billed in the office setting, including overall management, care coordination,individual and group psychotherapy, and substance use counseling; for billing codes, refer toHCPCS G2086–G2088Page 4 of 33MLN1986542 June 2021
Medicare Mental Health Caregiver-focused behavioral health risk assessmentof their own behavior and health risks, which benefitsthe patient Chemical and electrical aversion therapy to conditiona person to avoid undesirable behavior by pairing thebehavior with unwanted stimuli Cognitive Assessment and Care Planning, acomprehensive evaluation of a new or existingpatient who exhibits signs and symptoms of cognitiveimpairment, required to establish or confirm adiagnosis, etiology, and condition severity Chronic Care Management (CCM) and ComplexChronic Care Management for patients with multiplechronic conditions which place the person at high risk Annual depression screening, up to 15 minutes,when staff-assisted depression care supports canassure accurate diagnosis, effective treatment, andfollow-up; screening by clinical staff in the primarycare setting who can advise the physician of resultsand coordinate treatment referrals Diagnostic psychological and neuropsychological testsMLN BookletOpioid Treatment ProgramsEffective January 2020, CMS payscertified Opioid Treatment Programs(OTPs) through bundled paymentsfor OUD treatment services underMedicare Part B. Covered servicesinclude FDA-approved opioidagonist and antagonist medication,assisted treatment medications andtheir administration (if applicable),substance use counseling, individualand group therapy, toxicology testing,intake, and periodic assessments.Find more information in theOpioid Treatment Program Directory. Drug therapy or pharmacological management using medication(s) to treat disease; most MedicareDrug Plans have drug management programs for at-risk patients enrolled in Medicare Part D Drug withdrawal treatment to monitor the signs and symptoms from removal or a decrease in theregular drug dose Electroconvulsive therapy (ECT) treating depression and other mental illness using electric currentto the head Family psychotherapy with or without the patient present, as medically reasonable and necessary,with patient treatment as the primary purpose Health and behavioral assessment and intervention identifying or treating the psychological,behavioral, emotional, cognitive, and social factors important to prevent, treat, or manage physicalhealth issues Hypnotherapy Individual and group psychotherapy may be individual therapy with 1 or more therapists or morethan 1 individual in a therapy session with 1 or more therapists Individual activity therapy as part of a Partial Hospitalization Program (PHP) and may be cognitive,physical, social, and spiritual and not recreational or diversionary Initial Preventive Physical Examination (IPPE) to review medical and social health history andpreventive services educationPage 5 of 33MLN1986542 June 2021
Medicare Mental HealthMLN Booklet Interactive psychotherapy Medication management when a patient agrees to a medication treatment option for a trial periodand is monitored for its effectiveness Medication-Assisted Treatment (MAT) uses medications with counseling and behavioral therapyto treat substance use disorders including OUDs; effective January 2020, when a certified OTPprovider treats OUDs, Medicare pays for certain medications and services Narcosynthesis, a form of narcoanalysis where the patient recalls repressed memoriesunder hypnosis PHP, a structured and intensive program of outpatient psychiatric services, is an alternative toinpatient psychiatric care provided during the day that doesn’t require an overnight stay, through ahospital outpatient department or community mental health center Psychiatric collaborative care services uses BHI to enhance primary care services and includes apsychiatric consultant Psychoanalysis treats mental disorders by investigating the interaction of conscious andunconscious elements Psychiatric evaluation systematically evaluates the causes, symptoms, and course andconsequences of a psychiatric disorder Screening, Brief Intervention, and Referral to Treatment (SBIRT) services is early interventionfor individuals with non-dependent substance use to help them prevent more extensive orspecialized treatment Substance use disorder treatment in a patient’s home is now an acceptable telehealth servicessite for substance use treatment or a co-occurring mental disorder Tobacco use cessation counseling Therapeutic activities which can improve the patient’s condition, such as occupational therapy,recreational therapy, and milieu therapies Transitional care management, within 30 days of discharge from an inpatient hospital setting,interactive contact, certain non-face-to-face services, and face-to-face visits Urgently needed care to treat a sudden illness or injury that doesn’t need emergency medicalattention to prevent disability or deathPage 6 of 33MLN1986542 June 2021
Medicare Mental HealthMLN BookletPrescription Drug CoverageMedicare Part D covers prescription drugs. Medicare Part A and Part B generally don’t cover drugs,but Part B covers some medications patients can’t self-administer. For other prescription coverage,patients must enroll in a separate Medicare Drug Plan. Medicare Advantage enrollees can get Part A,Part B, and Part D benefits under a single plan.Medicare Drug Plans cover certain protected mental health treatment drug classes, includingantipsychotics, antidepressants, and anticonvulsants. Medicare Drug Plans must cover mostmedications in these drug classes, with some exceptions.Medicare Advantage OrganizationsIn addition to providing all Medicare Part B covered mental health services, Medicare Advantageplans may offer “additional telehealth benefits” (telehealth benefits beyond what Part B pays), as wellas supplemental benefits that aren’t covered under Medicare Parts A or B. For example, these mentalhealth supplemental benefits may address areas like coping with life changes, conflict resolution, orgrief counseling, all offered as individual or group sessions.Non-Covered Medicare Fee-for-Service Mental Health ServicesMedicare doesn’t cover these mental health services: Environmental intervention or modifications Adult day health programs Report preparation Results or data interpretation or explanation Biofeedback training (any modality) Marriage counseling Hemodialysis specifically for treatingschizophrenia (experimental) Transportation or outpatient meals Pastoral counseling Phone services, or “apps”Eligible ProfessionalsMedicare recognizes these Part B providers as eligible to provide diagnostic and BHI or SBIRTservices, as permitted under state law: Physicians (Medical Doctors [MDs] andDoctors of Osteopathy [DOs]), particularlyPsychiatrists Clinical Psychologists (CPs) Clinical Social Workers (CSWs)Page 7 of 33MLN1986542 June 2021 Clinical Nurse Specialists (CNSs) Nurse Practitioners (NPs) Physician Assistants (PAs) Certified Nurse-Midwives (CNMs) Independently Practicing Psychologists (IPPs)
Medicare Mental HealthMLN BookletProvider InformationThese tables list individual provider-type required qualifications, coverage, and payment criteria.Each provider type must meet all qualification and coverage requirements. For a list of specific billingcodes, see the Commonly Used CPT Codes section.Table 1. PsychiatristRequired Qualifications MD or DO Act within scope of yourlicensePage 8 of 33CoveragePayment Legally authorized to practicemedicine in the state where youprovide services Medicare doesn’t statutorilypreclude the services, and they’rereasonable and necessary You may provide the generalsupervision assigned todiagnostic psychological andneuropsychological tests You may provide servicesand supplies incident to yourprofessional services Paid at 100% underMedicare Physician FeeSchedule (PFS)MLN1986542 June 2021
Medicare Mental HealthMLN BookletTable 2. Clinical Psychologist (CP)Required QualificationsCoveragePayment Psychology Doctoral degree Legally authorized to practice Paid only onmedicine in the state where youassignment basis Licensed or certified in theprovideservices Paid at 100% ofstate where you practice at Medicare doesn’t statutorilythe independent level andassigned services underdirectly provide diagnostic,preclude the services, and they’reMedicare PFSassessment, preventive, andreasonable and necessarytherapeutic patient services If the patient consents, you mustattempt to consult their attendingor primary care physician aboutprovided services and either: Document consentor declination date toconsultations and date ofconsultations in patient’smedical record If consultations areunsuccessful, documentthe patient’s medical chartwith the date and physiciannotification method (doesn’tapply if physician referredpatient to CP) You may generally supervisediagnostic psychological andneuropsychological tests You may provide servicesand supplies incident to yourprofessional services, except forhospital patient servicesPage 9 of 33MLN1986542 June 2021
Medicare Mental HealthMLN BookletTable 3. Clinical Social Worker (CSW)Required Qualifications Social Work Master’s orDoctoral degree At least 2 years of supervisedclinical social work Licensed or certified asCSW by the state where youprovide services If you practice in a state thatdoesn’t have licensure orcertification, and completeat least 2 years or 3,000supervised social workpractice clinical hours,post-Master’s degree inan appropriate setting (forexample, a hospital, SkilledNursing Facility [SNF], orclinic)Page 10 of 33CoveragePayment Paid only on Legally authorized to practiceassignment basismedicine in the state where youprovide services Paid at 75% of CP’s Medicare doesn’t statutorilyMedicare PFSpreclude the services, and they’rereasonable and necessary You provide services to diagnoseand treat mental illnesses Medicare doesn’t pay CSWservices to hospitalized patientswith no CSW services coverage Medicare covers hospitaloutpatient CSW services andpays under the CSW benefitwhen billed by the hospitalunder CSW’s National ProviderIdentifier Medicare doesn’t cover CSWservices to patients underPHP by a hospital outpatientdepartment or CommunityMental Health Center Medicare doesn’t cover CSWservices to SNF inpatients andpatients in Medicare-participatingEnd-Stage Renal Diseasefacilities, or pay them underthe CSW benefit if the servicesmeet the respective participationrequirements Medicare may cover incidentto services CSWs provide forphysicians, CPs, CNSs, NPs,PAs, or CNMs Medicare doesn’t cover servicesincident to your personalprofessional servicesMLN1986542 June 2021
Medicare Mental HealthMLN BookletTable 4. Clinical Nurse Specialist (CNS)Required Qualifications Registered Nurse (RN)currently licensed in thestate where you practiceand authorized to provideCNS services according tostate law Doctor of Nursing Practiceor Master’s degree in adefined clinical nursingarea from an accreditededucational institution Certified as a CNS bya recognized nationalcertifying body withestablished CNS standardsPage 11 of 33CoveragePayment Legally authorized to practice Paid only onmedicine in the state where youassignment basisprovide services Paid at 85% of amount Medicare doesn’t statutorilyphysician gets underpreclude the services, and they’reMedicare PFSreasonable and necessary Medicare directly pays Medicare considers the servicesyou for assistant-atphysicians’ services if providedsurgery services at 85%by an MD or DOof 16% of the amounta physician gets under You provide the services with aMedicare PFSphysician Medicare may cover assistant-atsurgery services you provide You may personally providediagnostic psychological andneuropsychological tests with aphysician as required under CNSbenefit and as permitted understate law Medicare may cover incident toservices and suppliesMLN1986542 June 2021
Medicare Mental HealthMLN BookletTable 5. Nurse Practitioner (NP)Required Qualifications RN licensed and authorizedby the state where youprovide NP servicesaccording to state law: Got Medicare NP billingprivileges for first timesince January 1, 2003,and: Are NP-certified by arecognized nationalcertifying body withestablished NPstandards Master’s degree innursing or a Doctorof Nursing PracticeDoctoral degreeCoverage Paid only on Legally authorized to practiceassignment basismedicine in the state where youprovide services Paid at 85% of amount Medicare doesn’t statutorilyphysician gets underMedicare PFSpreclude the services, and they’rereasonable and necessary Medicare directly pays Medicare considers the servicesyou for assistant-atsurgery services at 85%physicians’ services if providedof 16% of the amountby an MD or DOaphysician gets under You provide the services whileMedicare PFSworking in collaboration witha physician Medicare may cover assistant-atsurgery services you provide You may personally providediagnost
Medicare Learning Network. Medicare Mental Health. MLN Booklet . PHP, a structured and intensive program of outpatient psychiatric services, is an alternative to inpatient psychiatric care provided during
