Nov-Dec 2000 Table of Contents

Getting Paid

Understanding Medicare's Mental Health Treatment Limitation



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Medicare significantly limits its mental health coverage, but you can protect your bottom line by knowing the rules.

Fam Pract Manag. 2000 Nov-Dec;7(10):15-16.

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Unfortunately, when you provide mental health services to your Medicare patients, your usual Medicare payments are reduced. By holding the patient responsible for the difference between the amount paid by Medicare and the full allowed amount, you should still be able to collect what you usually would for the service. The key is understanding Medicare's outpatient mental health treatment limitation well enough that you know what services it applies to and can explain it to your patients.

What is the limitation?

By law, Medicare payment for outpatient mental health services is limited to 62.5 percent of covered expenses incurred in any calendar year in connection with the treatment of a mental, psychoneurotic or personality disorder for an individual who is not an inpatient of a hospital at the time the expenses are incurred.

What does it include?

Three key components of the definition determine the scope of the limitation:

  • “Treatment.” The limitation applies to treatment; it does not generally apply to diagnosis.

  • “Mental, psychoneurotic, or personality disorder.” The limitation applies to the specific psychiatric conditions described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

  • “An individual who is not an inpatient of a hospital.” The limitation applies to services provided in outpatient departments, a physician's office, the patient's home, a skilled nursing facility, etc., including services provided at comprehensive outpatient rehabilitation facilities. Items and supplies furnished by physicians or other mental health professionals in connection with treatment are also subject to the limitation.

What isn't included?

While Medicare's outpatient mental health treatment limitation can seem pretty broad, there are services that fall outside its scope, including the following:

  • Medical services related to a diagnosis of Alzheimer's disease or related disorders. Medical management (rather than psychiatric treatment) of Alzheimer's disease (ICD-9 code 331.0) or Alzheimer's or other disorders coded in the 290 series in DSM is not subject to the limitation. However, when the primary treatment rendered to a patient with such a diagnosis is psychotherapy, it is subject to the limitation.

  • Brief office visits for monitoring or changing drug prescriptions. According to the regulations, the term “treatment” does not include brief office visits for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic or personality disorders, so these services are not subject to the limitation. To help ensure that your reimbursement for such visits is not reduced, report them to Medicare using HCPCS code M0064 (brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic or personality disorders).

  • Diagnostic services. Tests and evaluations performed to establish or confirm the patient's diagnosis are not subject to the limitation. Diagnostic services include psychiatric or psychological tests and interpretations, diagnostic consultations and initial evaluations. However, follow-up diagnostic services done to evaluate the progress of a course of treatment are subject to the limitation.

An initial visit to a physician for professional services often combines diagnostic evaluation and initiation of therapy. Because such a visit is neither solely diagnostic nor solely therapeutic, Medicare deems the initial visit to be diagnostic, so that the limitation does not apply. In cases where diagnostic services require more than one visit, Medicare will not apply the limitation to the additional visits. However, when you bill for more than one visit for professional diagnostic services, expect your Medicare carrier to request documentation to justify the bill.

  • Partial hospitalization services not directly provided by a physician. These services are billed by hospitals and community mental health centers to Medicare fiscal intermediaries.

How is the limit applied?

If the primary diagnosis reported for a particular service is the same as or equivalent to a condition described in the DSM, the expense for the service is subject to the limitation except under the circumstances just described. When it is not clear whether the primary diagnosis meets the definition of mental, psychoneurotic or personality disorders, the Medicare carrier may contact you to clarify the diagnosis. Medicare recognizes that, in some cases, physicians will provide services for both psychiatric and nonpsychiatric conditions. When this occurs, the carrier is required to separate the psychiatric aspects of the treatment from the other charges. If the two components are not readily distinguishable, the carrier will allocate all of the charges to the primary diagnosis.

The Medicare carrier computes the limitation as follows: First, it determines the Medicare allowed payment amount for services subject to the limitation. Then, it multiplies this amount by 0.625. Finally, it subtracts any unsatisfied deductible and multiplies the remainder by 0.8 to obtain the amount of Medicare payment. You should hold the beneficiary responsible for the difference between the amount paid by Medicare and the full allowed amount.

For example, let's imagine a Medicare beneficiary presents to you with an apparent mental disorder. You perform a diagnostic evaluation that costs $350. That service is not subject to the limitation, and it satisfies the patient's Medicare deductible for the year. You then conduct 10 weekly therapy sessions for which you charge $125 each. The Medicare allowed amount is $90 each, for a total of $900. The Medicare carrier applies the limitation by multiplying 0.625 by $900, which equals $562.50. The carrier then multiplies 0.8 by $562.50, which equals $450 (i.e., the amount of Medicare payment). The beneficiary in this case is responsible for $450 (i.e., the difference between the Medicare payment and the allowed amount).

Like so many other Medicare regulations, the outpatient mental health treatment limitation is difficult to understand. But with this explanation and the resolve to collect more money from the beneficiary, you can minimize any negative consequences to your practice's bottom line.

Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management.

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