First Coast Service Options Inc. (First Coast) recently conducted post payment provider specific probes reviews in response to data aberrancies identified for Current Procedural Terminology® (CPT®) code 90834 (psychotherapy, 45 minutes with patient and/or family member). Post payment medical reviews resulted in high error rates. Services were denied because submitted medical records did not meet documentation requirements as outlined in The Psychiatric Diagnostic Evaluation and Psychotherapy Services Local Coverage Determination (LCD) (L33128). Specifically the medical records were missing one or more of the following documentation requirements for each date of service:
• Documentation of measurable goals on the treatment plan;
• Detailed summary of the psychotherapy sessions, including descriptive documentation of therapeutic interventions;
• Degree of patient participation and interaction with the therapist;
• Reaction of the patient to the therapy sessions;
• Documented progress toward measurable goals since the last sessions; and changes or lack of changes in the patient’s symptoms or behavior;
• Documentation of adjustments in the treatment plan that reveal the dynamics of treatment;
• Treatment plan was not updated and did not support the medical necessity of each psychotherapy session.
The documentation for psychotherapy services should include on a periodic basis the patient’s capacity to participate and benefit from psychotherapy. Such periodic documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, measurable and objective goals of therapy related to changes in behavior, thought processes and/or medications, methods of monitoring outcome, and why the chosen therapy is an appropriate modality either in lieu of or in addition to another form of psychiatric treatment. For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient. For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected. Documentation will reflect adjustments in the treatment plan that reveals the dynamics of treatment.
It is expected that the treatment plan for a patient receiving outpatient psychotherapy (i.e., measurable and objective treatment goals, descriptive documentation of therapeutic intervention, frequency of sessions, and estimated duration of treatment) will be updated on a periodic basis, generally at least every three months.
The medical record documentation maintained by the provider must indicate the medical necessity of each psychotherapy session and include the following:
• The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning; and
• A detailed summary of the session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and
• The degree of patient participation and interaction with the therapist, the reaction of the patient to the therapy session, documentation toward goal oriented outcomes and the changes or lack of changes in patient symptoms and/or behavior as a result of the therapy session.
• The rationale for any departure from the plan or extension of therapy should be documented in the medical record. The therapist must document patient/therapist interaction in addition to an assessment of the patient’s problem(s).
First Coast recommends providers be familiar with medical necessity indications and documentation requirements for psychotherapy services as indicated in the Psychiatric Diagnostic Evaluation and Psychotherapy Services LCD. LCDs are available through the CMS Medicare coverage database at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx external pdf file