Service-specific post-payment review of Psychotherapy, 60 minutes with the patient – CPT 90837
The Medical Review Department will be conducting a service-specific post-payment review of the services mentioned. The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.
NGS has randomly selected claims billed for CPT 90837 for post-payment review in Jurisdiction K for Part B providers in the states of New York, Connecticut, Massachusetts, Rhode Island, Vermont, Maine, and New Hampshire.
- 90837 Psychotherapy, 60 minutes with the patient
If a claim is selected for review, the provider will receive an ADR letter. Providers, with claims selected for review, must submit the requested documentation within 45 days of the date on the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.
For psychotherapy, psychiatric therapeutic procedure code, CPT 90837, the medical record must include:
- An individualized treatment plan, updated treatment plans, and or the required components, and the plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals.
- The medical record must indicate the time spent in the psychotherapy encounter and indicate the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change.
- A periodic summary of goals and progress toward goals must be included in the medical record.
- The medical records must also include a clinical note for each encounter, wherein the aggregate summarizes the following items: diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis, and progress to date. Elements such as treatment plans, functional status, and prognostic assessment are expected to be documented, updated, and available for review, but do not need to be delineated for each individual date of service.
- Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
- Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient’s condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning. When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary.
- The services must be performed by persons authorized by their state to render psychotherapy services.
It is important to submit all documentation that supports the medical necessity of CPT 90837. The medical record must be legible and the name of the beneficiary, the date of service, and the signature of the rendering provider clearly identified. Please ensure all documentation to support the medical necessity of the billed service is submitted for review.