Important Change in Rules for Providing Group Psychotherapy Services Paid for by Medicaid
The Illinois Department of Healthcare and Family Services has posted a new Provider Notice to the Physicians Provider Notices page. http://www.hfs.illinois.gov/physicians/
These rules became effective October 1, 2009. Physicians may contact a physician billing consultant for additional billing information or questions regarding this notice at 1-877-782-5565.
1. HFS 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.
2. 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.
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