423 Form

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Medical Policy Outpatient Psychotherapy Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History

Policy Number: 423

BCBSA Reference Number: N/A

Related Policies
• Neuropsychological and Psychological Testing, #151 • Repetitive Transcranial Magnetic Stimulation (rTMS), #297 • Complementary Medicine - Hypnotherapy, #178 (CPT code 90880) • Biofeedback for Miscellaneous Conditions, #187 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Outpatient psychotherapy is a covered service (see coding section of policy for applicable codes).

Psychoanalysis is considered NOT MEDICALLY NECESSARY. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2 Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following codes are covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity. No policy criteria need to be met. No prior authorization is required:

CPT Codes: Routine Outpatient Psychotherapy
CPT codes:

Code Description 90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services 90832 Psychotherapy, 30 minutes with patient
90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90837 Psychotherapy, 60 minutes with patient
90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for a primary procedure) 90846 Family psychotherapy (without the patient present), 50 minutes 90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes 90849 Multiple-family group psychotherapy 90853 Group psychotherapy (other than of a multiple-family group)

CPT Codes: Outpatient Psychotherapy Crisis CPT codes:

Code Description 90839 Psychotherapy for crisis; first 60 minutes 90840 Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)

The following codes are considered non covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity.

CPT Codes: Other Psychotherapy CPT codes:

Code Description 90845 Psychoanalysis

Description Psychotherapy consists of face-to-face encounters providing psychologically-based treatment designed to alleviate symptoms and restore functioning for individuals with maladaptive coping mechanisms, mental illnesses and substance use disorders. Varieties of evidence-based psychotherapies exist for specific conditions and should be matched to those conditions.

Traditionally, individual psychotherapy services were referred to as the “50 minute hour.” In 2013, the coding structure was changed from codes with three discrete time blocks to a set of codes that span a range of codes and overlap in the amount of time covered. Routine individual psychotherapy sessions generally last 16 to 52 minutes, are delivered face to face with the patient, and include 5 to 10 minutes of documentation time.

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Psychodynamic therapy is a specific treatment modality that is based on aspects of psychoanalytic theory, evaluating how unconscious thought processes may be impacting thoughts and behavior. The technique utilized in practice is specific, usually conducted once per week and occurring face-to-face. The number of sessions may mirror traditional psychotherapy. The therapist may be trained in psychoanalysis or psychodynamic therapy and use these modalities to address specific behaviors and thought processes in practice. The American Psychological Association supports treatment with psychodynamic therapy in the context of helping individuals identify how thoughts, beliefs and patterns that may have originated throughout the lifespan may be affecting functioning and overall health.

Psychoanalysis is a theoretical model of psychopathology that seeks to evaluate how repressed emotions and unconscious processes may affect conscious thought and behavior. A typical course of treatment for psychoanalysis is conducted multiple times per week, face-to-face, by a specially trained psychotherapist over the period of 2-5 years on average. techniques may be used in session to help individuals identify unconscious thoughts and mental processes. While literature demonstrates improvements in symptoms of depression for individuals who undergo psychoanalysis, the individualized nature of treatment, lack of outcomes-based measures, limited understanding of appropriate target populations, and lack of comparative data make determining overall health outcomes difficult to establish.

Summary Many theoretical models of psychotherapy have been widely studied and are supported by the American Medical Association and American Psychological association. Target populations for specific modes of treatment have been evaluated and are established as evidenced based treatment models. Examples include cognitive behavioral therapy, exposure therapy, substance use therapy and psychotherapy for post-traumatic stress disorder.

In some therapeutic models, such as Psychoanalysis, supporting evidence is limited. Comparative data showing the effects of Psychoanalysis as an alternative model of treatment are not available. The evidence is insufficient to determine the effects of the technology on net health outcomes.

Policy History Date Action 1/1/26 Annual policy update. Description, summary and references reviewed. Policy statements unchanged. 1/1/26.
11/1/24 Annual policy update. Description, summary and references reviewed. Policy statements unchanged. Coding clarified. 11/1/24 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
7/2020 BCBSMA policy review. Description, summary and references updated. Policy statement on biofeedback training transferred to policy 187, Biofeedback for Miscellaneous Indications. 1/2019 Notification requirement table removed for clarification. 1/29/2019.
5/2018 Notification requirements clarified.
1/2018 Administrative requirements for Commercial members removed. Effective 1/1/2018. 12/2017
Coding information clarified to no longer require specific diagnoses for coverage with CPT codes 90837 and 90838. Effective 12/1/2017 retroactive to 1/1/2017.
3/2017 Clarified note. 1/2017 Removed prior authorization requirement for the first 12 psychotherapy sessions described by CPT codes 90837 and 90838 for Commercial Managed Care (HMO and POS) members. Coding information clarified. Effective 1/1/2017. 12/2016 Prior authorization information for Medicare HMO Blue and Medicare PPO Blue clarified. 12/1/2016

4 7/2016 Policy updated to remove from the coding section that psychotherapy must be conducted in person to be reimbursed. 7/20/2016. 1/2015 Prior authorization information for psychotherapy sessions (90837 and 90838) added.
Coding information clarified. Effective 1/1/2015. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
2/2012 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements.
2/2011 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements.
12/3/2010 Annual policy review. Changes to policy statements.
10/2009 Annual policy review. Changes to policy statements. 9/2009 Annual policy review. Changes to policy statements. 7/2009 Annual policy review. Changes to policy statements. 2/2009 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology, and Endocrinology. No changes to policy statements.
1/2009 Annual policy review. Changes to policy statements. 9/2008 Annual policy review. No changes to policy statements.
5/2008 Annual policy review. Changes to policy statements. 4/2008 Annual policy review. Changes to policy statements. 2/2008 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology, and Endocrinology. No changes to policy statements.
2/2007 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology, and Endocrinology. Changes to policy statements.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. American Academy of Child & Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007; 46(2):267-283.
2. American Academy of Child & Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007; 46(11):1503-1526-283.
3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association Publishing; 2013.
4. American Psychiatric Association Practice Guidelines, Borderline Personality Disorder. Arlington, VA: American Psychiatric Association Publishing; October 2001, Guideline Watch; March 2005.
5. American Psychiatric Association Practice Guidelines, Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Publishing; November 2004, Guideline Watch; March, 2009.
6. American Psychiatric Association Practice Guidelines, Major Depressive Disorder. Arlington, VA: American Psychiatric Association Publishing; November 2010.
7. American Psychiatric Association Practice Guidelines, Obsessive-Compulsive Disorder. Arlington, VA: American Psychiatric Publishing; July 2007, Guideline Watch; March 2013.
8. American Psychiatric Association Practice Guidelines, Panic Disorder. Arlington, VA: American Psychiatric Association Publishing; January 2009.

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9. Massachusetts General Law, MGL Chapter 176G Section 4M: Mental health benefits; biologically- based mental disorders; rape-related mental disorders; non-biologically-based mental disorders of children and adolescents under age 19. Retrieved from: http://www.mass.gov/legis/laws/mgl/176g- 4m.htm
10. National Institute of Mental Health. Mental Health Information: Anxiety Disorders 2016. Retrieved from: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
11. 2010. Mar 23, The Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111- 148, 124 Stat. 119.
12. PCIT International. Mental Health Information: Anxiety Disorders 2016. Retrieved from: http://www.pcit.org/pcit-research.html
13. Substance Abuse and Mental Health Services Administration. SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP). Traumatic Incident Reduction 2011. Retrieved from: http://legacy.nreppadmin.net/ViewIntervention.aspx?id=245
14. United States Department of Veterans Affairs. PTSD: National Center for PTSD – Eye Movement Desensitization and Reprocessing (EMDR) for PTSD 2016b. Retrieved from: http://www.ptsd.va.gov/public/treatment/therapymed/emdr-for-ptsd.asp
15. United States Department of Veterans Affairs. PTSD: National Center for PTSD – Prolonged Exposure Therapy for PTSD 2016a. Retrieved from: http://www.ptsd.va.gov/public/treatment/therapy- med/prolonged-exposuretherapy.asp