This article explains guidelines for payment of Part B mental health services including qualification requirements for mental health providers (physicians, non-physician practitioners and suppliers), and incident to services.
Mental health services that may be covered under the Medicare program include:
Psychiatric diagnostic interviews
Individual psychotherapy
Interactive psychotherapy
Family psychotherapy (with the patient present and the primary purpose is treatment of the individual’s condition);
Family psychotherapy (without the patient present, is medically reasonable and necessary, and the primary purpose is treatment of the individual’s condition)
Group psychotherapy
Psychoanalysis
Pharmacologic management
Electroconvulsive therapy (ECT)
Diagnostic psychological and neuropsychological tests
Hypnotherapy
Narcosynthesis
Biofeedback therapy
Individualized activity therapy (as part of a partial hospitalization program [PHP] and that is not primarily recreational or diversionary)
Mental health services that are not covered under the Medicare program are:
Environmental intervention
Geriatric day care programs
Individual psychophysiological therapy that incorporates biofeedback training (any modality)
Marriage counseling
Pastoral counseling
Report preparation
Interpretation or explanation of results or data
Transportation and meals
Telephone services.
Medicare recognizes the following providers who are eligible under Part B to furnish diagnostic and/or therapeutic treatment for mental, psychoneurotic, and personality disorders as well as Medicare SBIRT (screening, brief intervention and referral to treatment) services, to the extent permitted under State law:
Physicians (medical doctors [MD] and doctors of osteopathy [DO]), particularly psychiatrists;
Clinical psychologists (CP)
Clinical social workers (CSW)
Clinical nurse specialists (CNS)
Nurse practitioners (NP)
Physician assistants (PA)
Certified nurse-midwives (CNM)
Independently Practicing Psychologists (IPP)
Required qualifications
EP |
Required qualifications |
Coverage |
Payment |
Physicians |
Is a MD or a DO; and Is acting within the scope of his or her license. |
He or she is legally authorized to practice medicine in the State in which the services are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. He or she may perform the general supervision assigned to diagnostic psychological and neuropsychological tests; and Services and supplies may be furnished incident to his or her professional services. |
Payment for assigned services is made at 100% of the amount a physician is paid under the Medicare Physician Fee Schedule. |
CP |
Has a Doctoral degree in psychology; and Is licensed or certified, on the basis of the Doctoral degree in psychology, by the State in which he or she practices at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals. |
He or she is legally authorized to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. Upon the patient’s consent, he or she must attempt to consult with the patient’s attending or primary care physician about the services being furnished and: Document the date of consent or declination of consent to consultations and the date of consultations in the patient’s medical record; or If consultations do not succeed, document the date and manner of notification to the physician in the patient’s medical record (does not apply if the physician referred the patient to the CP). He or she may perform the general supervision assigned to diagnostic psychological and neuropsychological tests; and Services and supplies may be furnished incident to his or her professional services, with the exception of services furnished to hospital patients |
Payment is made only on an assignment basis; and Services are paid at 100% of the amount a physician is paid under the Medicare Physician Fee Schedule. |
CSW |
Has a master's or Doctoral degree in social work; Has performed at least 2 years of supervised clinical social work; and Is licensed or certified as a CSW by the State in which the services are performed; or If the individual practices in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master's degree supervised clinical social work practice under the supervision of a master's level social worker in an appropriate setting (for example, a hospital, skilled nursing.) |
He or she is legally authorized to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary; Services are for the diagnosis and treatment of mental illnesses. CSW services furnished to hospital inpatients are not covered as CSW services; CSW services to hospital outpatients are covered and paid under the CSW benefit when billed by the hospital to a Medicare Administrative Contractor under the CSW’s National Provider Identifier. CSW services furnished to patients under a Partial Hospitalization Program that is provided by a hospital outpatient department or Community Mental Health Center are not covered and paid under the CSW benefit. CSW services furnished to SNF inpatients and patients in Medicare-participating End-Stage Renal Disease facilities are not covered and paid under the CSW benefit if the service furnished are required under the respective requirements for participation. Incident to services that CSWs furnish for physicians, CPs, CNSs, NPs, PAs, or CNMs may be covered; and Services furnished as an incident to a CSW’s personal professional services are not covered. |
Payment is made only on an assignment basis; and Services are paid at 75% of the amount a CP is paid under the Medicare Physician Fee Schedule. |
CNS |
Is a registered nurse currently licensed to practice in the State where the individual practices and is authorized to furnish the services of a CNS in accordance with State law. Has a Doctor of Nursing practice or master's degree in a defined clinical area of nursing from an accredited educational institution; and Is certified as a CNS by a recognized national certifying body that has established standards for CNS. |
He or she is legally authorized and qualified to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. Services are the type considered physicians’ services if furnished by a MD or a DO. Services are performed in collaboration with a physician. Assistant-at-surgery services furnished by a CNS are covered. He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the CNS benefit and to the extent permitted under State law; and Incident to services and supplies may be covered |
Payment is made only on an assignment basis. Services are paid directly to the CNS at 85% of the amount a physician is paid under the Medicare Physician Fee Schedule (PFS); and Payment is made directly to the CNS for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the Medicare PFS for assistant-at-surgery services. |
NP |
Is a registered professional nurse authorized by the State in which the services are furnished to practice as a NP in accordance with State law and meets one of the following criteria: Obtained Medicare billing privileges as a NP for the first time on or after January 1, 2003, and: Is certified as a NP by a recognized national certifying body that has established standards for NPs; and Has a master's degree in nursing or a Doctor of Nursing Practice Doctoral degree; Obtained Medicare billing privileges as a NP for the first time before January 1, 2003, and meets the certification requirements described above; or Obtained Medicare billing privileges as a NP for the first time before January 1, 2001. |
He or she is legally authorized and qualified to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. Services are the type considered physicians’ services if furnished by a MD or a DO. Services are performed in collaboration with a physician. Assistant-at-surgery services furnished by a NP are covered. He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the NP benefit and to the extent permitted under State law; and Incident to services and supplies may be covered. |
Payment is made only on an assignment basis. Services are paid at 85% of the amount a physician is paid under the Medicare Physician Fee Schedule (PFS); and Payment is made directly to the NP for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the Medicare PFS for assistant-at-surgery services. |
PA |
Is licensed by the State to practice as a PA and one of the following criteria: Has graduated from a PA educational program accredited by the Accreditation Review Commission on education for the physician assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs, and the Committee on Allied Health Education and Accreditation); or Has passed the national certification examination administered by the National Commission on Certification of physician assistants. |
He or she is legally authorized to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. Services are the type considered physicians’ services if furnished by a MD or a DO. Services are performed by an individual who meets all PA qualifications. Services are performed under the general supervision of a MD or a DO. The physician supervisor or designee need not be physically present when a service is being furnished unless State law or regulations require otherwise. Assistant-at-surgery services furnished by a PA are covered. He or she may personally perform diagnostic psychological and neuropsychological tests under the general supervision of a physician as required under the PA benefit and to the extent permitted under State law; and Incident to services and supplies may be covered. |
Payment is made only on an assignment basis; Payment may be made only to his or her: Qualified employer who is eligible to enroll in the Medicare Program under existing provider/supplier categories; or - Contractor. Services are paid at 85% of the amount a physician is paid under the Medicare PFS (Physician Fee Schedule); and Payment is made to the PA’s employer or contractor for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the Medicare PFS for assistant-at- surgery services. |
CNM |
Is a registered nurse who is legally authorized to practice as a nurse-midwife in the State where services are performed. Has successfully completed a program of study and clinical experience for nurse-midwives that is accredited by an accrediting body approved by the U.S. Department of Education; and Is certified as a nurse-midwife by the American College of Nurse-Midwives or the American College of Nurse-Midwives Certification Council. |
He or she is legally authorized and qualified to furnish the services in the State where they are performed. Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary. Services are the type considered physicians services if furnished by a MD or a DO. Services are performed without physician supervision and without association with a physician or other health care provider, unless otherwise required by State law. He or she may personally perform diagnostic psychological and neuropsychological tests without physician supervision or oversight as authorized under the CNM benefit and to the extent permitted under State law; and Incident to services and supplies may be covered. |
Payment is made only on an assignment basis; and Services are paid at 80% of the lesser of the actual charge or 100% of the amount a physician is paid under the Medicare Physician Fee Schedule. |
IPP |
Is a psychologist who is not a CP; and Meets one of the following criteria: Practices independently of an institution, agency, or physician’s office and is licensed or certified to practice psychology in the State or jurisdiction where the services are performed; or Is a practicing psychologist who performs services in a jurisdiction that does not issue licenses |
Performs services on his or her own responsibility, free of the administrative and professional control of an employer (for example, a physician, an institution, or an agency). The individuals treated are his or her own patients. When he or she practices in an office that is located in an institution: The office is confined to a separately identified part of the facility that he or she uses solely as an office and cannot be construed as extending throughout the entire institution; and He or she conducts a private practice (services are furnished to patients outside the institution as well as to institutional patients). He or she may perform diagnostic psychological and neuropsychological tests when a physician orders such tests; and He or she has the right to bill directly and collect and retain the fee for his or her services. |
Diagnostic psychological and neuropsychological tests are not subject to assignment; however, the name and address of the physician who ordered the tests must be included on the claim form; and Assigned payment is made to the IPP at 100% of the Medicare. |
Incident to a physician’s professional services means the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.
A physician, CP, CNS, NP, PA, or CNM may have outpatient psychiatric services and supplies furnished incident to his or her professional service. To be covered under the Incident to provision, the following requirements must be met: ™
The services and supplies must be an integral part of the patient’s normal course of treatment during which the physician or other listed NPP has personally performed an initial service and remains actively involved in the course of treatment. ™
The services and supplies are commonly furnished without charge (included in the physician’s or other listed NPP’s bill). ™
The services and supplies are an expense to the physician or other listed NPP.
The services and supplies are commonly furnished in the physician’s or other listed NPP’s office or clinic; and ™
The physician or other listed NPP provides direct supervision, which means he or she is present in the office suite and immediately available if needed.
Services and supplies furnished by CPs, CSWs, CNSs, NPs, PAs, and CNMs may also be covered when furnished as an incident to the professional services of a physician or other specified NPP if they would have been covered when furnished incident to the services of a MD or a DO.
MFT and MHC services are defined as services for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital).
MFT and MHC services are covered when furnished in a rural health clinic and federally qualified health center.
An MFT or MHC is defined as an individual who possesses a master's or doctor's degree, is licensed or certified by the State in which they furnish services, and who has performed at least 2 years or 3,000 hours of clinical supervised experience and meets other requirements as the Secretary determines appropriate.
All Marriage and Family therapists and Mental Health Counselors billing Medicare will be required to enroll with Medicare. Provider specialty codes (E1 and E2) have been developed.
Services will be paid at 75 percent of the Medicare Physician Fee Schedule (MPFS).
If services are billed with type of bill 85X for these professional services rendered in a Method II Critical Access Hospital (CAH), they have the option of reassigning their billing rights and payment for their services to the CAH. When the billing rights are reassigned to the Method II CAH, payment is made to the CAH. The CAH payment amount for MFT and MHC services is 80% of the lesser of the actual charge or 75% of the MPFS.
If "incident to" requirements are not met, services provided by an NPP (e.g., CP, NP, CNS, PA, CNM, or LCSW) who have been credentialed by Medicare and obtained a Medicare provider number - Provider Transaction Number (PTAN), must submit claims using their own National Provider Identifier (NPI) number as the rendering provider.
A provider may not hire and supervise a practitioner outside of his/her own scope of practice.
Practitioners not able to receive a Medicare provider number may bill incident to a MD/DO, CP, NP, CNS, PA, or CNM.
In a hospital setting charges incident to the CP are bundled into the hospital payment.
Services performed by auxiliary personnel in an inpatient or outpatient hospital setting are not covered as “incident to” services.
Services provided by auxiliary personnel not employed by the physician, are not covered as “incident to” services.
Services of the following practitioners must be provided under the scope of clinical practice as authorized by the state where they practice.
Doctorate or master level psychologist
Doctorate or Master level social worker
Clinical nurse specialists (CNS)/ nurse practitioners (NP)
The person providing the service signs the medical record.
Medicare Claims Processing Manual Publication 100-04, Chapter 12
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