PCPA has been working with HGSAdministrators (a Medicare Part B Carrier) for many months to reverse a potentially devastating position. HGSA had issued an interpretation indicating that psychotherapy services could not be provided as “incident to.” After numerous letters, phone calls, and meetings, HGSA has published a revision to the interpretation previously issued.According to the HGSA web site (www.hgsa.com), the update published in their newsroom on April 24 reverses their interpretation and allows psychotherapy services to be provided as “incident to” where “...non-coverage of such services would limit access to ‘reasonable and necessary’ care of the Medicare patient(s)” and where the provider “...clearly documents their concerns and rationale in the patients' medical records (in addition to each patient's clinical record documentation).”
HGSA stated that psychotherapy services provided "incident to" must be in keeping with all five elements of the "incident to" guidelines, as well as all national regulations, statutes, Local Medical Review Policies (e.g. LMRP V-41D on Psychiatric Therapeutic Procedures), and Centers for Medicare and Medicaid Services (CMS) directives, to include the recent CMS Transmittal, AB-03-037, Change Request 2520, published on the HGSA website on March 28.
In addition, HGSA has clarified LMRP V-41D to state, “The supervised individual delivering (performing) the service must be licensed or authorized by the State. HGSA interprets ‘licensed or authorized by the State’ to include both individuals and facilities licensed or authorized by the State of Pennsylvania to perform such services.”
This update will be published in the June 2003 Medicare Report, be effective retroactively to December 1, 2002, and will remain in effect otherwise announced. PCPA and HGSA will work together to further research the issue and reach a consensus with CMS regarding the ability of psychotherapy to be provided “incident to.”
HGSA also reiterated that if a psychotherapy service is provided that does not meet all “incident to” guidelines, this should be billed with a “GY” modifier in order to receive a denial. The full text of the update is available from the Association. PCPA would like to extend special thanks to the Pennsylvania Psychological Association for their collaborative efforts on this endeavor.
Contact Rebecca May Cole with any questions.