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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 7
Section 3.11
Issue Date:  December 5, 1984
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-13, November 15, 2017
90804 - 90857 for care provided through December 31, 2012.
90832 - 90853 for care provided on or after January 1, 2013.
Psychotherapy is the treatment for mental health and Substance Use Disorders (SUDs) in which the clinician establishes a professional contact with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.
3.1  Benefits are available for inpatient and outpatient psychotherapy that is medically or psychologically necessary to treat a covered mental disorder.
3.2  Individual psychotherapy for patients diagnosed with a mental disorder (Diagnostic and Statistical Manual of Mental Disorders (DSM)), including SUD is a covered benefit.
3.3  Charges for outpatient psychotherapy are not covered when the patient is an inpatient in an institution. Claims for outpatient psychotherapy must be denied for the entire period during which the beneficiary is an inpatient in the institution.
3.4  Employees of institutional providers are not authorized to bill for services rendered as part of that employment. Such services billed by the employee must be denied.
3.5  Eye Movement Desensitization and Reprocessing (EMDR) is covered for the treatment of Post-Traumatic Stress Disorder (PTSD) in adults.
3.6  Psychotherapy is not a Health and Behavior Assessment/Intervention. See Section 16.2.
3.7  Across all behavioral health settings (outpatient mental health and SUD, Opioid Treatment Programs (OTPs), Intensive Outpatient Programs (IOPs), Partial Hospitalization Program (PHPs), Residential Treatment Centers (RTCs), inpatient/residential Substance Use Disorder Rehabilitation Facilities (SUDRFs), and acute inpatient), the following standardized measures will be required at treatment baseline, at 60-120 day intervals, and at discharge for the corresponding diagnoses:
•  Post-Traumatic Stress Disorder (PTSD) - PTSD Checklist (PCL)
•  Generalized Anxiety Disorder (GAD) - GAD-7
•  Major Depressive Disorder (MDD) - Patient Health Questionnaire - 8 (PHQ-8)
3.8  Notification of the referring military provider or Military Treatment Facility (MFT)/Enhanced Multi-Service Markets (eMSM) referral management office (on behalf of the military provider) is required when a Service member or beneficiary, in the provider’s clinical judgment, meets any of the following criteria:
•  Harm to self - The provider believes there is a serious risk of self-harm by the Service member either as a result of the condition itself or medical treatment of the condition;
•  Harm to others - There is a serious risk of harm to others either as a result of the condition itself or medical treatment of the condition. This includes any disclosures concerning child abuse or domestic violence;
•  Harm to mission - There is a serious risk of harm to a specific military operational mission. Such a serious risk may include disorders that significantly impact impulsivity, insight, reliability, and judgment;
•  Inpatient care - Admitted or discharged from any inpatient mental health or substance use treatment facility as these are considered critical points in treatment and support nationally recognized patient safety standards;
•  Acute medical conditions interfering with duty - Experiencing an acute mental health condition or is engaged in an acute medical treatment regimen that impairs the beneficiary’s ability to perform assigned duties;
•  Substance abuse treatment program - Entered into, or is being discharged from, a formal outpatient or inpatient treatment program.
3.9  Timely notification to the referring military provider or MTF/eMSM referral management office (on behalf of the military provider) of the circumstances listed in paragraph 3.8 is necessary to ensure the safety of the Service member or beneficiary by the MTF/eMSM, which is ultimately responsible for their care.
4.1  Maximum duration of psychotherapy sessions for care provided through December 31, 2012:
4.1.1  Inpatient or outpatient individual psychotherapy (Current Procedural Terminology (CPT) procedure codes 90806, 90807, 90818, 90819) approximately 45 to 50 minutes; or (CPT procedure codes 90804, 90805, 90816, 90817) approximately 20 to 30 minutes.
4.1.2  Inpatient or outpatient group, conjoint or family psychotherapy: 90 minutes (CPT procedure codes):
4.1.3  Crisis intervention (CPT procedure codes):
90808 - PSYTX, OFFICE, 75-80 MIN
90809 - PSYTX, OFF, 75-80, W/E&M
90821 - PSYTX, HOSP, 75-80 MIN
90822 - PSYTX, HOSP, 75-80 MIN W/E&M
4.2  Maximum duration of psychotherapy sessions for care provided on or after January 1, 2013:
4.2.1  Inpatient or outpatient individual psychotherapy: 30 minutes (CPT procedure codes 90832 and 90833); 45 minutes (CPT procedure codes 90834 and 90836); or 60 minutes (CPT procedure codes 90837 and 90838).
4.2.2  Inpatient or outpatient group, conjoint or family psychotherapy (CPT procedure codes):
4.2.3  Crisis intervention (CPT procedure codes):
4.3  Frequency of psychotherapy sessions.
4.3.1  Multiple sessions the same day: If the multiple sessions are of the same type, payment may be made only if the circumstances represent crisis intervention and only according to the restrictions applicable to crisis intervention. A collateral session not involving the identified patient on the same day the patient receives a therapy session does not require review. Patients who require multiple sessions on the same day may require a higher level of care such as IOP or PHP.
4.3.2  Collateral visits (CPT procedure code 90887). Collateral visits are payable when medically or psychologically necessary for treatment of the identified patient. A collateral visit is considered to be a psychotherapy session for purposes of reviewing the duration or frequency of psychotherapy.
4.3.3  Psychoanalysis (CPT procedure code 90845). Psychoanalysis is covered when provided by a graduate or candidate of a psychoanalytic training institution recognized by the American Psychoanalytic Association and when preauthorized by the contractor.
4.3.4  Play therapy. Play therapy is a form of individual psychotherapy which is utilized in the diagnosis and treatment of children with mental health disorders. Play therapy is a benefit, subject to the regular points of review applicable to individual psychotherapy.
4.3.5  Marathon therapy. Marathon therapy is a form of group therapy in which the therapy sessions last for an extended period of time, usually one or more days. Marathon therapy is not covered since it is not medically necessary or appropriate.
4.3.6  Inpatient psychotherapy and medical care. The allowable charge for inpatient psychotherapy includes medical management of the patient. A separate charge for hospital visits rendered by the provider on the same day as he/she is rendering psychotherapy is not covered. Payment is authorized only for medically necessary hospital visits billed on a day that psychotherapy was not rendered. If the provider who is primarily responsible for treatment of the mental disorder is not a physician, charges for medical management services by a physician are coverable, but only if the physician is rendering services that the non-physician provider is prohibited from providing. Concurrent inpatient care by providers of the same or different disciplines is covered only if second or third level review determines that the patient’s condition requires the skills of multiple providers.
4.3.7  Physical examination. A physical examination is an essential component of the work up of the psychiatric patient, and for all admissions should be performed either by the attending psychiatrist or by another physician. The examination may lead to confirmation of a known psychiatric diagnosis or consideration of other unsuspected psychiatric or medical illness. When not performed by the attending psychiatrist, payment may be made to another physician for performance of the initial physical examination. Any additional concurrent care provided by a physician other than the attending psychiatrist may be covered only if it meets the criteria under inpatient concurrent care.
5.1  November 13, 1984.
5.2  April 16, 2007, for EMDR for the treatment of PTSD in adults.
5.3  October 3, 2016, elimination of quantitative limits for psychotherapy.
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