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October 28, 2021

Targeted Probe and Educate Program to Focus on Psychotherapy Service Claims

The CGS Targeted Probe and Educate program will begin review of claims associated with outpatient psychotherapy services. Guidance for psychotherapy services provision and documentation may be found in the CGS’ LCD L34353External Website located in the Part B Medical Policies section of the CGS website.

All psychotherapy services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations, and manual provisions.

Hospital outpatient psychiatric services must be: [1] incident to a physician's service, and [2] reasonable and necessary for the diagnosis or treatment of the patient's condition (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1). This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient's condition. In all cases, the appropriate documentation must be kept on file and, upon request. The psychotherapy service must meet all program coverage criteria in order for payment to be made.

We expect the documentation submitted to include a copy of the following legible and signed documentation from each patient's medical record:

  1. Beneficiary’s name
  2. Date of service
  3. Documentation of time
  4. Individualized Treatment plan:
    • Type
    • Amount
    • Frequency
    • Duration of services to be furnished
    • Diagnoses
    • Anticipated goals
  5. Reasonable expectation of improvement or reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate.
  6. Clinical note:
    • supporting face to face visit with the patient
    • supporting therapeutic maneuvers; communication attempts supportive or interpretive interactions to produce a therapeutic change
    • that summarizes
      1. Diagnosis
      2. Symptoms
      3. Functional status
      4. Mental status examination
      5. Treatment plan
      6. Prognosis
      7. Progress
      8. Name, signature and credential of the person performing the service
  7. Periodic summary of
    1. Goals
    2. Progress towards goals
    3. Updated treatment plan if applicable
  8. Appropriate signatures
    • Signature and credentials of person performing the service
    • Amendments/corrections/delayed entries are properly identified
    • Amendments/corrections/delayed entries are initialed and dated by author within 30 days of the billed service.

For additional documentation requirements, please reference:

CPT codes under review will include:

  • 90832- Psychotherapy, 30 minutes with patient
  • 90834- Psychotherapy, 45 minutes with patient
  • 90837- Psychotherapy, 60 minutes with patient

For more information on Targeted Probe and Educate, please see the following links:

Consider using the myCGS Portal for claim review status and submission of documentation. For more information, please access myCGS


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