Page 151 - Medicare Benefit Policy Manual

A/B MACs (B) are required to familiarize themselves with appropriate State laws and/or
regulations governing a CP’s scope of practice.

D. Noncovered Services

The services of CPs are not covered if the service is otherwise excluded from Medicare
coverage even though a clinical psychologist is authorized by State law to perform them.
For example, §1862(a)(1)(A) of the Act excludes from coverage services that are not
“reasonable and necessary for the diagnosis or treatment of an illness or injury or to
improve the functioning of a malformed body member.” Therefore, even though the
services are authorized by State law, the services of a CP that are determined to be not
reasonable and necessary are not covered. Additionally, any therapeutic services that are
billed by CPs under CPT psychotherapy codes that include medical evaluation and
management services are not covered.

E. Requirement for Consultation

When applying for a Medicare provider number, a CP must submit to the A/B MAC (B)
a signed Medicare provider/supplier enrollment form that indicates an agreement to the
effect that, contingent upon the patient’s consent, the CP will attempt to consult with the
patient’s attending or primary care physician in accordance with accepted professional
ethical norms, taking into consideration patient confidentiality.

If the patient assents to the consultation, the CP must attempt to consult with the patient’s
physician within a reasonable time after receiving the consent. If the CP’s attempts to
consult directly with the physician are not successful, the CP must notify the physician
within a reasonable time that he or she is furnishing services to the patient. Additionally,
the CP must document, in the patient’s medical record, the date the patient consented or
declined consent to consultations, the date of consultation, or, if attempts to consult did
not succeed, that date and manner of notification to the physician.

The only exception to the consultation requirement for CPs is in cases where the patient’s
primary care or attending physician refers the patient to the CP. Also, neither a CP nor a
primary care nor attending physician may bill Medicare or the patient for this required
consultation.

F. Outpatient Mental Health Services Limitation

All covered therapeutic services furnished by qualified CPs are subject to the outpatient
mental health services limitation in Pub 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and
Payment Limitations,” §30, (i.e., only 62 1/2 percent of expenses for these services are
considered incurred expenses for Medicare purposes). The limitation does not apply to
diagnostic services.