Provider Notice issued 01/30/13

Change in Coverage of Group Psychotherapy

Rulemaking regarding the department's policies for group psychotherapy sessions rendered in the Encounter Rate Clinic (ERC), Federally Qualified Health Center (FQHC), and Rural Health Clinic (RHC) clinic setting have been adopted. This rulemaking sets forth the requirements that must be met for group psychotherapy services rendered in any of these clinic settings to be eligible for reimbursement from HFS.

Effective with dates of service February 1, 2013, and after, the department will pay for up to two group psychotherapy sessions in a 7-day period, with a maximum of one session per day. The limit of two applies to all sessions, even if billed by different physicians. To be eligible for reimbursement the group psychotherapy session must meet all of the following requirements:

• Patient's medical record must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases (ICD-9-CM) or the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Group psychotherapy sessions must be billed with a valid ICD-9-CM diagnosis within code range 290 through 319;

• Entire group psychotherapy service is directly performed by a physician who has completed an approved general psychiatry residency program or is a resident or attending physician at an accredited psychiatric residency program, as evidenced by the physician's signature on the patient medical record for each date of service. Services provided by psychologists, social workers, advanced practice nurse, etc. are not reimbursable;

• Group size does not exceed 12 patients, regardless of payment source for any group member;

• Minimum duration of a group session is forty-five (45) minutes;

• Group session is documented in the patient's medical record by the rendering physician, including the session's primary focus, level of patient participation and the begin and end times of each session;

• Group treatment model, methods, and subject content have been selected on evidence-based criteria for the target population of the group and follows recognized practice guidelines for psychiatric services; and

• Group session is provided in accordance with a clear written description of goals, methods, and referral criteria.

Group psychotherapy is not covered for residents of a nursing facility, including a nursing facility classified as an institution for mental diseases, or a facility licensed under the Specialized Mental Health Rehabilitation Act.

Group Session Requirements

Participants are limited to two group psychotherapy sessions per week. Different physicians may render the service. Claims received for more than two sessions in a 7-day period by any physician or clinic for a participant will be rejected. The rejection message will be K01 – Limit 2 Group Psych Visits in 7 Days.

Psychiatric Residency Certification

Physicians planning to render group psychotherapy and attending physicians submitting claims on behalf of services rendered by a resident must have an HFS 3882 (pdf), Psychiatric Residency Certification and a copy of the accredited psychiatric residency completion certificate or a letter from the residency program verifying completion on file with the department. Claims for group psychotherapy rendered by a physician who does not have an HFS 3882 on file with the department will be rejected. The rejection message will be G98 – Psychiatric Residency Not On File.

The clinic must ensure, and document, that the physician meets the department's requirements for group psychotherapy services since the clinic is receiving reimbursement for a medical encounter.

Any questions regarding this notice may be directed to a medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs