Chapter 7
Section 3.7
Treatment
Of Mental Disorders - General
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-24, October 31, 2024
1.0 CPT 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 Authorized Individual Professional
Providers
Only the
types of providers listed below are considered qualified providers
of mental health services. The person providing the care shall 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 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 shall be brought
to the attention of the Managed Care Support Program Section (MCSPS)
or TRICARE Overseas Program Office (TOPO), immediately. The contractor
shall notify institutional providers within its 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 shall 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 3.15).
Note: Institutional benefits for
SUDs are covered in
Section 3.5.
5.2 Professional Services
5.2.1 Individual psychotherapy, adult
or child (see
Section 3.11);
5.2.5 Psychological testing and assessment
(see
Section 3.9);
5.2.6 Specific mental health coverage
descriptions are outlined in eating disorder treatment (see
Section 3.14), specific learning disorder
(see
Section 3.6), Attention Deficit Hyperactivity
Disorder (ADHD) (see this Section), and Gender Dysphoria (GD) and
Gender-Affirming Health Care for dates of service on or after July
1, 2022 (see
Section 1.3);
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) 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.
5.2.10 Medication Assisted Treatment
(MAT) (see
Section 3.17);
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 codes 90867, 90868, and 90869),
is proven.
5.2.14 Spravato™ (esketamine) nasal
spray (Healthcare Common Procedure Coding System (HCPCS) code J3490)
(CPT codes G2082-83) for the treatment of treatment-resistant depression
and other US 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.
5.2.15 Allowable services that are necessary
to diagnose and treat ADHD may be cost-shared.
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).
• 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.
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).
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
3.17.
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 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.
7.7 Prescription
digital therapeutics (EndeavorRx), including associated devices
and mobile medical applications, for the treatment of ADHD is unproven.
7.8 Off-label
use of external trigeminal nerve simulation (eTNS) for the treatment
of PTSD is excluded.
7.9 Prescription digital therapeutics
(NightWare), including the associated devices and mobile medical applications,
for the treatment of nightmares associated with PTSD is unproven.
7.10 Non-invasive vagus nerve
stimulation (nVNS), also referred to as transcutaneous vagus nerve
stimulation (tVNS) for the treatment of PTSD is unproven.
8.0 EFFECTIVE
DATES
8.1 May 31, 2014, TMS (also referred
to as repetitive TMS (rTMS)) for the treatment of major depressive disorder,
is proven.
8.2 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.
8.3 Removal of all remaining quantitative
treatment limitations on mental health care, and inclusion of IOPs, October
3, 2016.
8.4 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).