TRICARE Manuals - Display Chap 7 Sect 3.8 (Change 86, Jul 14, 2021)

Medicine

Chapter 7

Section 3.8

Treatment Of Mental Disorders - General

Issue Date: December 5, 1984

Authority: 32 CFR 199.4(c)(3)(ix)

Revision: C-75, November 13, 2020

1.0 CPT PROCEDURE CODE RANGES

90801 - 90899, 96101-96103, 96118-96120 for care provided through December 31, 2012.

90785 - 90899, 96101-96103, 96118-96120 for care provided on or after January 1, 2013.

90785-90899, 96112, 96113, 96121, 96130-96133, 96136-96139, and 96146 for care provided on or after January 1, 2019.

2.0 HCPCS Codes

G0502-G0504 and G0507 for care provided on or after January 1, 2017.

3.0 POLICY

Benefits are payable for services and supplies that are medically or psychologically necessary for the treatment of mental disorders when:

3.1 The services are rendered by persons who meet the criteria of 32 CFR 199.6 for their respective disciplines (whether the person is an individual professional provider or is employed by another authorized provider), and

3.2 The mental disorder is a nervous or mental condition that involves a clinically significant behavioral or psychological syndrome or pattern that is associated with a painful symptom, such as distress, and that impairs a patient’s ability to function in one or more major life activities. A Substance Use Disorder (SUD) is a mental condition that involves a maladaptive pattern of substance use leading to clinically significant impairment or distress; impaired control over substance use; social impairment; and risky use of a substance(s). Additionally, the mental disorder must be one of those conditions listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). “Conditions Not Attributable to a Mental Disorder,” or V codes (Z codes in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)), are not considered diagnosable mental disorders. Co-occurring mental and SUDs are common and assessment should proceed as soon as it is possible to distinguish the substance related symptoms from other independent conditions.

4.0 POLICY CONSIDERATIONS

Professional and Institutional Providers of Mental Health Services.

4.1 List of authorized individual professional providers. Only the types of providers listed below are considered qualified providers of mental health services. The person providing the care must meet the criteria of 32 CFR 199.6, whether that person is an individual, professional provider or is employed by another authorized provider.

• Psychiatrists and other physicians;

• Clinical psychologists;

• Certified Psychiatric Nurse Specialists (CPNSs);

• Certified Clinical Social Workers (CCSWs);

• TRICARE Certified Mental Health Counselors (TCMHCs);

• Certified marriage and family therapists;

• Pastoral counselors; and

• Supervised Mental Health Counselors (SMHCs).

4.2 List of institutional providers. Only the types of institutional providers listed below are considered qualified institutional providers of mental health services. The care must meet the criteria of 32 CFR 199.6.

• Acute Hospital Psychiatric Care;

• Residential Treatment Centers (RTCs);

• Psychiatric Partial Hospitalization Programs (PHPs); and

• Intensive Outpatient Programs (IOPs).

Note: Professional staff of institutions providing mental health services. For professional services billed by institutional providers that are authorized by the Defense Health Agency (DHA), reviewers may assume that all professional staff meet regulatory criteria. Any evidence to the contrary is to be brought to the attention of the TRICARE Regional Office (TRO), immediately. Contractors shall notify institutional providers within their jurisdictions that payment is authorized only for professional services provided by employees meeting the program requirements. In any situation where the contractor obtains evidence that an institution is billing for professional services of unqualified staff, the case is to be submitted to the DHA Office of Program Integrity (PI).

5.0 COVERED SERVICES AND TREATMENTS

All claims for treatment of mental disorders are subject to review in accordance with claims processing procedures contained in the TRICARE Operations Manual (TOM). The following services and supplies are covered:

5.1 Institutional Benefits

5.1.1 Medically or psychologically necessary acute hospital psychiatric care (see Section 3.1);

5.1.2 Medically or psychologically necessary psychiatric RTC care for children and adolescents, up to age 21 (see Section 3.2);

5.1.3 Medically or psychologically necessary psychiatric PHP care (see Section 3.4);

5.1.4 Medically or psychologically necessary psychiatric IOP care (see Section 3.16).

Note: Institutional benefits for SUDs are covered in Section 3.5, paragraph 3.2.1.

5.2 Professional Services

5.2.1 Individual psychotherapy, adult or child (see Section 3.11);

5.2.2 Group psychotherapy (see Section 3.11);

5.2.3 Family or conjoint psychotherapy (see Section 3.12);

5.2.4 Psychoanalysis (see Section 3.11, paragraph 4.3.3);

5.2.5 Psychological testing and assessment (see Section 3.10);

5.2.6 Specific mental health coverage descriptions are outlined in eating disorder treatment (see Section 3.15), specific learning disorder (see Section 3.6), Attention Deficit Hyperactivity Disorder (ADHD) (see Section 3.7), and Gender Dysphoria (see Section 1.2);

5.2.7 Administration of psychotropic drugs. All patients receiving psychotropic drugs must be under the care of a qualified mental health provider authorized by state licensure to prescribe drugs (see Section 3.12).

5.2.8 Electroconvulsive treatment (Current Procedural Terminology (CPT) procedure codes 90870 and 90871). Electroconvulsive treatment is covered when medically or psychologically appropriate and when rendered by qualified providers. However, the use of electric shock as negative reinforcement (aversion therapy) is excluded.

5.2.9 Collateral visits (see Section 3.14);

5.2.10 Medication Assisted Treatment (MAT) (see Section 3.18);

5.2.11 Ancillary therapies (no code, as separate reimbursement is not permitted). Includes art, music, dance, occupational, and other ancillary therapies, when included by the attending provider in an approved inpatient treatment plan and under the clinical supervision of a licensed doctoral level mental health professional. These ancillary therapies are not separately reimbursed professional services but are included within the institutional reimbursement.

5.2.12 All providers are expected to consult with, or refer patients to, a physician for evaluation and treatment of physical conditions that may co-exist with or contribute to a mental disorder.

5.2.13 Transcranial Magnetic Stimulation (TMS) (also referred to as repetitive TMA (rTMS)) for the treatment of major depressive disorder (CPT procedure codes 90867, 90868, and 90869), is proven.

5.2.14 Spravato™ (esketamine) nasal spray (HCPCS J3490) (CPT codes G2082-83) for the treatment of treatment-resistant depression and other U.S. Food and Drug Administration (FDA) approved indications, which is available to providers from the FDA’s Spravato™ Risk Evaluation and Mitigation Strategy (REMS) Program, may be cost-shared. Preauthorization under the medical benefit is required. See Chapter 1, Section 6.1 and TOM, Chapter 7, Section 2.

6.0 REFERRAL AND PREAUTHORIZATION REQUIREMENT

6.1 Referral

Normal TRICARE Prime referral requirements shall apply under the following conditions:

6.1.1 A Primary Care Manager (PCM) referral is required for inpatient (non-emergency psychiatric hospitalization or RTC) services.

6.1.2 A PCM referral is required for non-office based, outpatient (e.g., PHP or IOP) mental health services. However, if the non-office based, outpatient mental health provider is a network provider, a request for preauthorization from the network provider to the contractor may be accepted in lieu of the PCM referral.

6.1.3 Office-based, outpatient mental health services by an authorized TRICARE network provider do not require a referral.

6.1.4 Point Of Service (POS) charges shall apply when services are rendered by a non-network office-based, outpatient mental health individual provider without a PCM referral when network providers are available in the TRICARE Prime Service Area (PSA).

6.2 Preauthorization

6.2.1 Medically or psychologically necessary outpatient mental health (PHP, IOP, or office) visits do not require preauthorization. However, the contractor may utilize preauthorization as a means of ensuring medical or psychological necessity absent a PCM referral (see paragraph 6.1.2). Exceptions include:

• Psychoanalysis requires preauthorization (see Chapter 1, Section 6.1, paragraph 1.5).

• Electroconvulsive treatment requires preauthorization to ensure the beneficiary has failed to respond to a less intensive form of treatment or that less intensive intervention is not more appropriate.

• TMS requires preauthorization to ensure the beneficiary has failed to respond to a less intensive form of treatment or that a less intensive intervention is not more appropriate.

6.2.2 Preauthorization is required for all non-emergency inpatient and residential levels of care. Contractors may establish additional preauthorization requirements in accordance with the TOM, Chapter 8, Section 5, paragraph 4.0.

6.2.3 Inpatient hospital services are considered medically necessary only when the patient’s condition is such that the personnel and facilities of a hospital are required. Preauthorization is not required for emergency admissions, but authorization for a continuation of services must be obtained promptly (see Section 3.1, paragraph 3.4.2).

7.0 EXCLUSIONS

7.1 Sexual dysfunctions, paraphilias, and paraphilic disorders (see Section 1.1).

7.2 Drug maintenance programs when one addictive drug is substituted for another on a maintenance basis, except as otherwise authorized in Sections 3.5 and 3.18.

7.3 Specific developmental disorders.

7.4 Microcurrent Electrical Therapy (MET), Cranial Electrotherapy Stimulation (CES), or any therapy that uses the non-invasive application of low levels of microcurrent stimulation to the head by means of external electrodes for the treatment of anxiety, depression, insomnia, or Post-Traumatic Stress Disorder (PTSD) and electrical stimulation devices used to apply this therapy (see Section 15.1).

7.5 Off-label use of Ketamine (subcutaneous, sublingual, IV, injectable, nasal spray, or orally) is excluded.

7.6 Off-label use of Spravato™ (esketamine) is excluded.

8.0 EFFECTIVE DATES

8.1 November 13, 1984.

8.2 May 31, 2014, TMS (also referred to as repetitive TMS (rTMS)) for the treatment of major depressive disorder, is proven.

8.3 Removal of day limits in any fiscal year for TRICARE beneficiaries of all ages for the provision of inpatient (including residential) mental health services on or after December 19, 2014.

8.4 Removal of all remaining quantitative treatment limitations on mental health care, and inclusion of IOPs, October 3, 2016.

8.5 Spravato™ (esketamine) nasal spray for the treatment of: treatment resistant depression, effective March 5, 2019; coverage for other FDA approved indications may be allowed on or after the date the indication was added to the label (e.g., August 3, 2020 for adults with major depressive disorder with acute suicidal ideation or behavior).

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