Provider Notice issued 08/31/09

To: Participating Physicians

Date: August 31, 2009

Re: Coverage of Group Psychotherapy
 

Rulemaking regarding the department's policies for group psychotherapy sessions have been adopted and become effective October 1, 2009. This rulemaking sets forth the requirements that must be met for group psychotherapy services to be eligible for reimbursement from HFS when billed by a physician. The rulemaking does not affect group psychotherapy services billed through 59 Illinois Administrative Code 132 (Rule 132) or Federally Qualified Health Centers.
 

Effective with dates of service October 1, 2009, 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 the billing physician. Services provided by psychologists, social workers, advanced practice nurse, etc., are not reimbursable;
• Group size does not exceed 12 patients, regardless of payment source;
• 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;
• Group session is provided in accordance with a clear written description of goals, methods, and referral criteria; and
• For participants who are residents of a long term care facility, the provider of the group psychotherapy must maintain documentation in the patient's medical record demonstrating the coordination of services and the sharing of information related to the patient's needs and the implementation and effectiveness of the patient's plan of care with the long term facility.

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 for a participant will be rejected. The rejection message will be K01 – Limit 2 Group Psych Visits in 7 Days.
 

Psychiatric Certification Requirement
 

Effective with dates of service January 1, 2010, and after, any physician billing group psychotherapy services must have completed an approved general psychiatry residency program or be providing the service as a resident or attending physician at an accredited residency program. Physicians planning to render group psychotherapy and attending physicians submitting claims on behalf of services rendered by a resident must have an HFS 3882, Psychiatric Residency Certification and a copy of the accredited residency completion certificate or a letter from the residency program verifying completion on file with the department. Refer to the April 28, 2009 notice and May 12, 2009 addendum regarding Psychiatric Residency Certification Requirement at: http://www.hfs.illinois.gov/physicians/ The August 1, 2009, effective date referenced in the May 12, 2009, addendum has been extended to January 1, 2010. The HFS 3882 and documentation verifying completion of the residency program should be mailed to:

Healthcare and Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, IL 62794-9114

Physicians are encouraged to submit the HFS 3882 and supporting documentation to the department as soon as possible. Effective with dates of service January 1, 2010, and after 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.
 

Resident Billing Requirements
 

Group psychotherapy sessions rendered by a resident must be submitted with the appropriate group psychotherapy CPT code and modifier GC (service has been performed in part by a resident under the direction of a teaching physician) or GE (service has been performed by a resident without the presence of a teaching physician under the primary care exception) and the school of medicine must be designated on the claim as the payee. Claims received for services provided by a resident that do not include the appropriate modifier and payee designation will be rejected. The rejection message will be G10 – Payee Must Be Medical School. Billing examples are included with this notice.

Physicians may contact a physician billing consultant for additional billing information or questions regarding this notice at 1-877-782-5565.
 

Theresa A. Eagleson, Administrator
Division of Medical Programs

Billing Examples for Group Psychotherapy Provided by a Resident (pdf)