Electroconvulsive Therapy (ECT) (L30493)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30493 LCD Title Electroconvulsive Therapy (ECT) Contractor's Determination Number PSYCH-025 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 07/15/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 02/21/2011 Revision Ending Date |
CMS National Coverage Policy
Social Security Act
Title XVIII of Social Security Act, § 1862 (a) (1) (A) this section allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, 1862 (a) (7) excludes routine physical examination and screening tests performed in the absence of signs and symptoms from coverage.
Title XVIII of Social Security Act, § 1833 (e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.
CMS Publications
CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.25.
CMS Publication, 100-04, Medicare Claims Processing Manual, Chapter 3, 190.7.3
CMS Publication 100-04, Medicare Benefit, Chapter 12, Section 50.
Code of Federal Regulations
42 CFR 410.155 Outpatient mental health treatment limitation.
42 CFR 412.113(c) Anesthesia services furnished by hospital or CAH employed non-physician anesthetists or obtained under arrangements.
42 CFR 412.50 Furnishing of inpatient hospital services directly or under arrangements.
42 CFR 482.13(b)(2) in the Patients Rights CoP discusses the patient s or patient s representative s right to make informed decisions regarding the patient s care.
42 CFR 482.24(c)(2)(v) in the Medical Records CoP discusses the requirement that the hospital must ensure that patient medical records contain properly executed informed consent forms for procedures or treatments specified by the hospital Medical Staff, or by Federal or State law if applicable, to require written patient consent.
CMS Medicare Carriers Manual, Transmittal 1816, Change Request 2682 dated August 22, 2003.
Program Memorandum AB-03-003, January 10, 2003. Non-coverage of Multiple Electrocardiograms. (MECT)
Title XVIII of Social Security Act, § 1862 (a) (1) (A) this section allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, 1862 (a) (7) excludes routine physical examination and screening tests performed in the absence of signs and symptoms from coverage.
Title XVIII of Social Security Act, § 1833 (e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.
CMS Publications
CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.25.
CMS Publication, 100-04, Medicare Claims Processing Manual, Chapter 3, 190.7.3
CMS Publication 100-04, Medicare Benefit, Chapter 12, Section 50.
Code of Federal Regulations
42 CFR 410.155 Outpatient mental health treatment limitation.
42 CFR 412.113(c) Anesthesia services furnished by hospital or CAH employed non-physician anesthetists or obtained under arrangements.
42 CFR 412.50 Furnishing of inpatient hospital services directly or under arrangements.
42 CFR 482.13(b)(2) in the Patients Rights CoP discusses the patient s or patient s representative s right to make informed decisions regarding the patient s care.
42 CFR 482.24(c)(2)(v) in the Medical Records CoP discusses the requirement that the hospital must ensure that patient medical records contain properly executed informed consent forms for procedures or treatments specified by the hospital Medical Staff, or by Federal or State law if applicable, to require written patient consent.
CMS Medicare Carriers Manual, Transmittal 1816, Change Request 2682 dated August 22, 2003.
Program Memorandum AB-03-003, January 10, 2003. Non-coverage of Multiple Electrocardiograms. (MECT)
Indications and Limitations of Coverage and/or Medical Necessity
Electroconvulsive therapy (ECT) is a procedure where electrodes are positioned on the patient s scalp, and measured electrical current is passed through to the brain. ECT is effective for a narrow range of psychiatric disorders. It is effective for mood disorders both bipolar and unipolar. It can also be used to augment the treatment of schizoaffective disorder and schizophrenia. Most ECT is performed to treat depression and is not typically the first-line of treatment. However, ECT works more quickly than medications and should be used as a first line treatment in life threatening catatonia or someone who is extremely suicidal. Research shows that ECT may be appropriate for patients with recurrences who were prior ECT responders and for refractory depression in patients with contraindications to medications or who are unwilling to take medications. When ECT is prescribed it should be part of a treatment plan overseen by a board certified psychiatrist in conjunction with other therapies when indicated.
Indications of Coverage:
ECT is a highly structured treatment involving a complex and repeatedly administered procedure. ECT should be used to achieve rapid resolution of severe symptoms. ECT may be most helpful when other treatments have failed, although there are situations when ECT can be used as a first line treatment. The decision to use ECT should be made jointly by the beneficiary and/or their legal representative and the clinicians responsible for treatment. Consent should be obtained where the patient and/or their legal representative is able to give such permission.
Pre-ECT Evaluation:
In accordance with the Task Force Report of the American Psychiatric Association, each facility administering ECT treatment will determine the requirements of a pre-ECT evaluation. Patient medical evaluation is an essential component of the pre-treatment process and may include but is not limited to:
1. Psychiatric history and examination, including past response to ECT treatments and a baseline neuropsychiatric evaluation.
2. Medical evaluation that includes history and examination (i.e. neurological, cardiovascular, pulmonary systems, and previous response to anesthesia).
3. Review of dental problems including examining loose or missing teeth, presence of dentures or other appliances.
4. Appropriate laboratory and diagnostic tests: common tests include but are not limited to complete blood count, serum electrolytes, electrocardiogram, chest x-ray, and pregnancy test on child-bearing age patients (determined on a case-by-case basis).
Treatment:
Prescribed therapy usually consists of six to 12 ECT treatments administered over a period of two to six weeks, after which a re-evaluation is recommended.
Primary indication:
According to the APA Task Force, ECT treatment could be prescribed as a first-line or primary treatment when a rapid or higher probability of response is needed and the patient symptomatology is severe. Situations would include, but are not limited to:
Primary or secondary severe major depression with/without psychotic features
Manic delirium
Acute mania
Catatonia
At risk for self harm or others
Medication-resistance or intolerance (i.e. anti-depressants and/or neuroleptic medications that pose a particular medical risk)
When ECT is safer than alternative treatments in conditions such as with the infirm elderly and during pregnancy
Secondary indication:
ECT treatment could be prescribed as a second-line or secondary treatment for patients that have the following, but are not limited to:
Poor or little response to other modalities of treatment
Deterioration in psychiatric condition
Onset of suicidal ideations or intent to harm self or others
Lack of or decrease in the will to live (i.e. exhaustion, dehydration, lack of vigor)
ECT Continuation or Maintenance:
Continuation or maintenance ECT may be used to reduce the risk for relapse and recurrence of illness. Treatments may be started on a weekly basis with the interval treatments gradually extended to a month, depending on patient response. Patient referral for maintenance ECT should meet one or more of the following indications:
History of illness that is responsive to ECT
History of medication-resistant depression
Medication intolerance or patient unwillingness to take medication.
Comorbid conditions that complicate management of the psychiatric disorder
Either non-compliance or intolerance to pharmacotherapy
Patient preference for continuation ECT therapy; and
Ability and willingness of the patient to comply with overall treatment plan to prevent relapse
ECT, including maintenance ECT, has been helpful for patients with Parkinsonism where pharmacotherapy with dopamine agonists or precursors is either of limited efficacies and/or precipitates psychosis or other severe behavioral or mental health changes and can be considered for medical necessity (Office of mental health).
For narcoleptic malignant syndrome (NMS) supportive care combined with immediate discontinuation of the causative agent is the primary treatment. NMS research shows ECT as an effective treatment and can be considered for coverage with supporting medical documentation.
ECT is generally initiated in an inpatient setting, but can be administered on an outpatient basis in a facility with treatment and recovery rooms where appropriate healthcare professionals are available and should include equipment and medications that could be used in the event of cardiopulmonary or other complications. Treatments are typically administered by a psychiatrist and an anesthesiologist, with a specially trained nurse in attendance.
Wisconsin Physicians Service considers ECT reasonable and necessary when one or more of the following indications of coverage is met:
Major depressive episode and/or major depressive disorder that meet the criteria according to the DSM-IV.
Depression with acute suicide risk, extreme agitation, or unresponsive to pharmacological therapy.
Bipolar illness with either mania or depression where medications are ineffective or not tolerated, or severe mania presenting a safety risk to the patient or to others.
Intolerance to the side effects of antidepressant medication or to antidepressant or psychotropic medications that pose a particular medical risk.
When rapid resolution of depression is necessary, e.g., the patient is acutely suicidal or physically compromised, and the time factor to achieve maximal effectiveness of antidepressants or mood stabilizers places the patient at immediate risk to health or safety.
Inability to medically tolerate maintenance medication.
Catatonia
Acute schizophrenia, or severe, life-threatening psychoses, which have not responded to, or cannot be treated with short term, high dose tranquilization.
When continuation of ECT treatments is necessary to sustain remission or to sustain significant improvement.
Limitations of Coverage
Multiple-Seizure Electroconvulsive Therapy:
Clinical Effectiveness of the multiple-seizure electroconvulsive therapy has not been verified by scientifically controlled studies. In addition, studies have demonstrated an increased risk of adverse effects with multiple seizures. Accordingly, MECT cannot be considered reasonable and necessary and is not covered by the Medicare Program. Effectiveness for services provid4ed on or after April 1, 2003 (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.25). Effective for dates of service on or after April 1, 2003, CMS Medicare will not pay for this therapy in any setting or under any code.
Although there are no €œabsolute € contraindications for ECT treatment, it is pertinent to weigh the relative risk to the potential benefits of treatment. There are medical conditions that substantially increase the risk of treatment and should be evaluated on a case-by-case basis by the attending physician and treating psychiatrist. Relative contraindications in ECT treatment include space-occupying lesions of the brain, high intracranial pressure, recent cerebral infarct (hemorrhagic or ischemic within past 90 days), recent myocardial infarction (six weeks for mild MI and up to six months for severe MI), retinal detachment, pheochromocytoma, high anesthesia risk, adolescents and children, or significant medical illness in which risk outweighs potential benefit. Careful evaluation is an essential component of the treatment process and may include consultations with internists, cardiologists, neurologists, and other specialties.
ECT is not considered reasonable and necessary for the following conditions/situations:
Alcoholism as the primary diagnosis
To aid in developing conditioned aversions to the taste, smell and sight of alcoholic beverages
Ability to tolerate effective antidepressant or psychotropic medications, and rapid resolution of depression is unnecessary because the patient is not a immediate risk of suicide
No evidence of ECT effectiveness in patients who have been treated previously (e.g. use of bilateral electrode placement for a series of 12 treatments)
Major depression and bipolar disorder when the patient tolerates and is responding to antidepressant medications
Indications of Coverage:
ECT is a highly structured treatment involving a complex and repeatedly administered procedure. ECT should be used to achieve rapid resolution of severe symptoms. ECT may be most helpful when other treatments have failed, although there are situations when ECT can be used as a first line treatment. The decision to use ECT should be made jointly by the beneficiary and/or their legal representative and the clinicians responsible for treatment. Consent should be obtained where the patient and/or their legal representative is able to give such permission.
Pre-ECT Evaluation:
In accordance with the Task Force Report of the American Psychiatric Association, each facility administering ECT treatment will determine the requirements of a pre-ECT evaluation. Patient medical evaluation is an essential component of the pre-treatment process and may include but is not limited to:
1. Psychiatric history and examination, including past response to ECT treatments and a baseline neuropsychiatric evaluation.
2. Medical evaluation that includes history and examination (i.e. neurological, cardiovascular, pulmonary systems, and previous response to anesthesia).
3. Review of dental problems including examining loose or missing teeth, presence of dentures or other appliances.
4. Appropriate laboratory and diagnostic tests: common tests include but are not limited to complete blood count, serum electrolytes, electrocardiogram, chest x-ray, and pregnancy test on child-bearing age patients (determined on a case-by-case basis).
Treatment:
Prescribed therapy usually consists of six to 12 ECT treatments administered over a period of two to six weeks, after which a re-evaluation is recommended.
Primary indication:
According to the APA Task Force, ECT treatment could be prescribed as a first-line or primary treatment when a rapid or higher probability of response is needed and the patient symptomatology is severe. Situations would include, but are not limited to:
Primary or secondary severe major depression with/without psychotic features
Manic delirium
Acute mania
Catatonia
At risk for self harm or others
Medication-resistance or intolerance (i.e. anti-depressants and/or neuroleptic medications that pose a particular medical risk)
When ECT is safer than alternative treatments in conditions such as with the infirm elderly and during pregnancy
Secondary indication:
ECT treatment could be prescribed as a second-line or secondary treatment for patients that have the following, but are not limited to:
Poor or little response to other modalities of treatment
Deterioration in psychiatric condition
Onset of suicidal ideations or intent to harm self or others
Lack of or decrease in the will to live (i.e. exhaustion, dehydration, lack of vigor)
ECT Continuation or Maintenance:
Continuation or maintenance ECT may be used to reduce the risk for relapse and recurrence of illness. Treatments may be started on a weekly basis with the interval treatments gradually extended to a month, depending on patient response. Patient referral for maintenance ECT should meet one or more of the following indications:
History of illness that is responsive to ECT
History of medication-resistant depression
Medication intolerance or patient unwillingness to take medication.
Comorbid conditions that complicate management of the psychiatric disorder
Either non-compliance or intolerance to pharmacotherapy
Patient preference for continuation ECT therapy; and
Ability and willingness of the patient to comply with overall treatment plan to prevent relapse
ECT, including maintenance ECT, has been helpful for patients with Parkinsonism where pharmacotherapy with dopamine agonists or precursors is either of limited efficacies and/or precipitates psychosis or other severe behavioral or mental health changes and can be considered for medical necessity (Office of mental health).
For narcoleptic malignant syndrome (NMS) supportive care combined with immediate discontinuation of the causative agent is the primary treatment. NMS research shows ECT as an effective treatment and can be considered for coverage with supporting medical documentation.
ECT is generally initiated in an inpatient setting, but can be administered on an outpatient basis in a facility with treatment and recovery rooms where appropriate healthcare professionals are available and should include equipment and medications that could be used in the event of cardiopulmonary or other complications. Treatments are typically administered by a psychiatrist and an anesthesiologist, with a specially trained nurse in attendance.
Wisconsin Physicians Service considers ECT reasonable and necessary when one or more of the following indications of coverage is met:
Major depressive episode and/or major depressive disorder that meet the criteria according to the DSM-IV.
Depression with acute suicide risk, extreme agitation, or unresponsive to pharmacological therapy.
Bipolar illness with either mania or depression where medications are ineffective or not tolerated, or severe mania presenting a safety risk to the patient or to others.
Intolerance to the side effects of antidepressant medication or to antidepressant or psychotropic medications that pose a particular medical risk.
When rapid resolution of depression is necessary, e.g., the patient is acutely suicidal or physically compromised, and the time factor to achieve maximal effectiveness of antidepressants or mood stabilizers places the patient at immediate risk to health or safety.
Inability to medically tolerate maintenance medication.
Catatonia
Acute schizophrenia, or severe, life-threatening psychoses, which have not responded to, or cannot be treated with short term, high dose tranquilization.
When continuation of ECT treatments is necessary to sustain remission or to sustain significant improvement.
Limitations of Coverage
Multiple-Seizure Electroconvulsive Therapy:
Clinical Effectiveness of the multiple-seizure electroconvulsive therapy has not been verified by scientifically controlled studies. In addition, studies have demonstrated an increased risk of adverse effects with multiple seizures. Accordingly, MECT cannot be considered reasonable and necessary and is not covered by the Medicare Program. Effectiveness for services provid4ed on or after April 1, 2003 (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.25). Effective for dates of service on or after April 1, 2003, CMS Medicare will not pay for this therapy in any setting or under any code.
Although there are no €œabsolute € contraindications for ECT treatment, it is pertinent to weigh the relative risk to the potential benefits of treatment. There are medical conditions that substantially increase the risk of treatment and should be evaluated on a case-by-case basis by the attending physician and treating psychiatrist. Relative contraindications in ECT treatment include space-occupying lesions of the brain, high intracranial pressure, recent cerebral infarct (hemorrhagic or ischemic within past 90 days), recent myocardial infarction (six weeks for mild MI and up to six months for severe MI), retinal detachment, pheochromocytoma, high anesthesia risk, adolescents and children, or significant medical illness in which risk outweighs potential benefit. Careful evaluation is an essential component of the treatment process and may include consultations with internists, cardiologists, neurologists, and other specialties.
ECT is not considered reasonable and necessary for the following conditions/situations:
Alcoholism as the primary diagnosis
To aid in developing conditioned aversions to the taste, smell and sight of alcoholic beverages
Ability to tolerate effective antidepressant or psychotropic medications, and rapid resolution of depression is unnecessary because the patient is not a immediate risk of suicide
No evidence of ECT effectiveness in patients who have been treated previously (e.g. use of bilateral electrode placement for a series of 12 treatments)
Major depression and bipolar disorder when the patient tolerates and is responding to antidepressant medications
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or MAC Part A. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or MAC Part B| 0901 | Behavioral Health Treatment/Services - Electroshock Treatment |
Listing of HCPCS codes contained in this instruction does not assure coverage of the specific service. Current coverage criteria still apply. When a psychiatrist performs both the ECT and the associated anesthesia, no separate payment is made for the anesthesia. Code 90870 is limited to use by physicians (MD/DO) only.
| 00104 | ANESTHESIA FOR ELECTROCONVULSIVE THERAPY |
| 90870 | ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY MONITORING) |
ICD-9 Codes that Support Medical Necessity
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
Non-covered diagnosis codes may be covered upon appeal on an individual consideration basis with supporting evidence of medical necessity. (Title XVIII of the Social Security Act, Section 1862(a) (1)(A). The codes selected are those codes which appear in the ICD-9-CM and that are defined in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR „¢).
Note: Every effort has been made to attempt to reflect the psychiatric diagnostic coding conventions of DSM-IV-TR „¢ in the psychiatric diagnoses section. Cases that fall outside DSM-IV-TR „¢ coding may be considered for coverage on a case-by-case basis.
Non-covered diagnosis codes may be covered upon appeal on an individual consideration basis with supporting evidence of medical necessity. (Title XVIII of the Social Security Act, Section 1862(a) (1)(A). The codes selected are those codes which appear in the ICD-9-CM and that are defined in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR „¢).
Note: Every effort has been made to attempt to reflect the psychiatric diagnostic coding conventions of DSM-IV-TR „¢ in the psychiatric diagnoses section. Cases that fall outside DSM-IV-TR „¢ coding may be considered for coverage on a case-by-case basis.
| 290.12 | PRESENILE DEMENTIA WITH DELUSIONAL FEATURES |
| 290.13 | PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES |
| 290.20 | SENILE DEMENTIA WITH DELUSIONAL FEATURES |
| 290.21 | SENILE DEMENTIA WITH DEPRESSIVE FEATURES |
| 290.42 | VASCULAR DEMENTIA, WITH DELUSIONS |
| 290.43 | VASCULAR DEMENTIA, WITH DEPRESSED MOOD |
| 293.83 | MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE |
| 294.10 | DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE |
| 294.11 | DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE |
| 295.20 - 295.25 | CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED STATE - CATATONIC TYPE SCHIZOPHRENIA IN REMISSION |
| 295.30 - 295.34 | PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE - PARANOID TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION |
| 295.40 - 295.44 | SCHIZOPHRENIFORM DISORDER, UNSPECIFIED - SCHIZOPHRENIFORM DISORDER, CHRONIC WITH ACUTE EXACERBATION |
| 295.70 - 295.74 | SCHIZOAFFECTIVE DISORDER, UNSPECIFIED - SCHIZOAFFECTIVE DISORDER, CHRONIC WITH ACUTE EXACERBATION |
| 295.80 - 295.84 | OTHER SPECIFIED TYPES OF SCHIZOPHRENIA UNSPECIFIED STATE - OTHER SPECIFIED TYPES OF SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION |
| 295.90 - 295.94 | UNSPECIFIED TYPE SCHIZOPHRENIA UNSPECIFIED STATE - UNSPECIFIED TYPE SCHIZOPHRENIA CHRONIC STATE WITH ACUTE EXACERBATION |
| 296.00 - 296.99 | BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED - OTHER SPECIFIED EPISODIC MOOD DISORDER |
| 298.0 - 298.9 | DEPRESSIVE TYPE PSYCHOSIS - UNSPECIFIED PSYCHOSIS |
| 300.4 | DYSTHYMIC DISORDER |
| 311 | DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED |
| 331.0 | ALZHEIMER'S DISEASE |
| 331.11 | PICK'S DISEASE |
| 331.19 | OTHER FRONTOTEMPORAL DEMENTIA |
| 331.2 | SENILE DEGENERATION OF BRAIN |
| 332.0 - 332.1 | PARALYSIS AGITANS - SECONDARY PARKINSONISM |
| 333.4 | HUNTINGTON'S CHOREA |
| 347.01 | NARCOLEPSY, WITH CATAPLEXY |
| 347.11 | NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITH CATAPLEXY |
| 995.29 | UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE |
Diagnoses that Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity
The ICD-9 codes not meeting the requirements for medical necessity in the narrative section titled €œIndications and Limitations € of this LCD.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
The medical record documentation will provide an explanation of why ECT is prescribed and must meet the conditions stated in the €œIndications and Limitations of Coverage and/or Medical Necessity € section of the LCD.
Any clinical history supporting the use of ECT needs to clearly document the medical reasonable and necessary conditions as described in the €œindications and limitations € section on the policy
Documentation supporting the medical necessity of this procedure must be a part of and kept in the medical record. It must be available upon request. Failure to provide the required documentation will result in a denial of the claim(s).
Documentation should include, but is not limited to, the following:
History and Physical Examination.
Medical record containing established psychiatric diagnosis according to the DSM-IV.
Medical records containing the patient s evaluation and management findings and treatments with relevant clinical signs, symptoms, and/or abnormal diagnostic/lab tests.
The clinical record should further indicate changes/alterations and response or non-response to medical management or treatment of the patient s condition and reflect the continued need and appropriateness of ECT based on psychiatrist s ongoing assessment and mental status examination of the patient during the course of treatments.
It is understood that any diagnostic and clinical information submitted and presented in the medical record must substantiate that the components of the procedure performed and billed were actually performed.
Procedure Record.
Appendices
Any clinical history supporting the use of ECT needs to clearly document the medical reasonable and necessary conditions as described in the €œindications and limitations € section on the policy
Documentation supporting the medical necessity of this procedure must be a part of and kept in the medical record. It must be available upon request. Failure to provide the required documentation will result in a denial of the claim(s).
Documentation should include, but is not limited to, the following:
History and Physical Examination.
Medical record containing established psychiatric diagnosis according to the DSM-IV.
Medical records containing the patient s evaluation and management findings and treatments with relevant clinical signs, symptoms, and/or abnormal diagnostic/lab tests.
The clinical record should further indicate changes/alterations and response or non-response to medical management or treatment of the patient s condition and reflect the continued need and appropriateness of ECT based on psychiatrist s ongoing assessment and mental status examination of the patient during the course of treatments.
It is understood that any diagnostic and clinical information submitted and presented in the medical record must substantiate that the components of the procedure performed and billed were actually performed.
Procedure Record.
Please refer to CMS Medicare publications, regulations, billing, and/or applicable LCDs for services that apply to CMS Medicare services for Electroconvulsive therapy services not covered in this policy or coding and billing guideline.
Tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury will be considered non-covered.
Exams required by insurance companies, business establishments, government agencies, or other third parties, without rationale for necessity will be denied.
Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statute.
Failure to provide documentation of the medical necessity of tests will result in denial of claims.
Beneficiary Liability
The beneficiary is not financially liable if services are denied as not medically reasonable and necessary unless an Advance Beneficiary Notice (ABN) is obtained.
The outpatient mental health limitation appears in 42 CFR 410.155 and applies to this policy.
This policy does not reflect the sole opinion of the contractor or medical director (CMD). Although the final decision rests with the contractor, this policy was developed in consideration of input from relevant interested parties and specialists.
Sources of Information and Basis for Decision
Tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury will be considered non-covered.
Exams required by insurance companies, business establishments, government agencies, or other third parties, without rationale for necessity will be denied.
Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statute.
Failure to provide documentation of the medical necessity of tests will result in denial of claims.
Beneficiary Liability
The beneficiary is not financially liable if services are denied as not medically reasonable and necessary unless an Advance Beneficiary Notice (ABN) is obtained.
The outpatient mental health limitation appears in 42 CFR 410.155 and applies to this policy.
This policy does not reflect the sole opinion of the contractor or medical director (CMD). Although the final decision rests with the contractor, this policy was developed in consideration of input from relevant interested parties and specialists.
WPS does not guarantee the continued availability of websites below.
American Psychiatric Association, Public Information, ECT. Available at: www.psych.org/public_info.
American Psychiatric Association. (1994). Practice guideline for the treatment of patients with bipolar disorder. AM J Psychiatry. 151 (12 Suppl): 1-36.
American Psychiatric Association (2000). Practice guideline for the treatment of patients with major depressive disorder. Psychiatry Online.1-49. Available at: http://www.psychiartyonline.com/popup.aspx?aID=49371&print=yes_chapter. Accessed on April 23, 2009.
American Psychiatric Association (2006). American Psychiatric Association, Task Force on Electroconvulsive Therapy: recommendations for treatment, training, and privileging (2nd ed). A Task Force Report of the American Psychiatric Association. Available at: http://www.ect.org/apa-task-force-report-on-electroconvulsive-therapy. Accessed on 05/11/2009.
Andrade, C. and Kurinji, S. (2002). Continuation and maintenance ECT: A review of recent research. Journal of ECT, September 18(3): 149-58.
Electroconvulsive Therapy. (1985) NIH Consensus Statement Online, Jun 10-12; 5(11): 1-23. Available at: http://consensus.nih.gov/1985/1985electroconvulsivetherapy051html.htm. Accessed on April 28, 2009.
Ellis, P. (2004). Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression. Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust NZ J Psychiatry, 38(6): 389-407.
Frederikse, M, Petrides, G, and Kellner, C. (2006). Continuation and maintenance therapy for the treatment of depressive illness: a response to the National Institute for Excellence report. Journal of ECT, March; 22(1): 13-17.
Geddes J, Carney S, Cowen P, et al. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet, 361 (9360): 799-808.
Greenberg, R., et al. (2005). Electroconvulsive Therapy: A Selected Review, American Journal of Geriatric Psychiatry, April 13(4).
Kahn, D; Carpenter, D; Docherty, J; Frances, A. Treatment of Bipolar Disorder (no date).
Lisanby, S. (2007). Electroconvulsive Therapy for Depression. New England Journal of Medicine, 357: 19: 1939-1945. Available at http://www.nejm.org. Accessed on April 28, 2009.
National Institute for Clinical Excellence (NICE) (2003, April). Guidance on the use of electroconvulsive therapy. Technical Appraisal 59. London, UK: NICE. Available at http://www.nice.org.uk/Docref.asp?d=68306. Accessed on April 28, 2009.
Onofrj, M, Thomas, A. (2005). Acute akinesia in Parkinson s disease. Neurology 2005; 64: 1162.
Sackeim, H, Haskett, R, Mulsant, B, et al. (2001). Continuation pharmacotherapy in the Prevention of Relapse following electroconvulsive therapy. The Journal of the American Medical Association, 285: 1299-1307. Available at: http://jama.ama-assn.org/cgi/content/full/285/10/1299. Accessed on May, 11, 2009.
Smith, D. (1995). Neuroleptic Malignant Syndrome. P&T News April, 1995, Volume 15, No. 10. Available at: http://www.healthcare.uiowa.edu/pharmacy/PTNews/1995/04.95.html. Accessed on June 1, 2009.
U.S. Department of Health and Human Services (2001, December), Office of the Inspector General. Medicare Reimbursement for electroconvulsive therapy. OEI-12-01-00450. Washington, DC; U.S. Department of health and Human Services. Available at http://oig.hhs.gov/oei/reports/oei-12-01-00450.pdf. Accessed on April 29, 2009.
US Department of Health and Human Services, €œClinical Practice Guidelines €, pp. 41, 95-96.
Advisory Committee Meeting Notes
American Psychiatric Association, Public Information, ECT. Available at: www.psych.org/public_info.
American Psychiatric Association. (1994). Practice guideline for the treatment of patients with bipolar disorder. AM J Psychiatry. 151 (12 Suppl): 1-36.
American Psychiatric Association (2000). Practice guideline for the treatment of patients with major depressive disorder. Psychiatry Online.1-49. Available at: http://www.psychiartyonline.com/popup.aspx?aID=49371&print=yes_chapter. Accessed on April 23, 2009.
American Psychiatric Association (2006). American Psychiatric Association, Task Force on Electroconvulsive Therapy: recommendations for treatment, training, and privileging (2nd ed). A Task Force Report of the American Psychiatric Association. Available at: http://www.ect.org/apa-task-force-report-on-electroconvulsive-therapy. Accessed on 05/11/2009.
Andrade, C. and Kurinji, S. (2002). Continuation and maintenance ECT: A review of recent research. Journal of ECT, September 18(3): 149-58.
Electroconvulsive Therapy. (1985) NIH Consensus Statement Online, Jun 10-12; 5(11): 1-23. Available at: http://consensus.nih.gov/1985/1985electroconvulsivetherapy051html.htm. Accessed on April 28, 2009.
Ellis, P. (2004). Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression. Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust NZ J Psychiatry, 38(6): 389-407.
Frederikse, M, Petrides, G, and Kellner, C. (2006). Continuation and maintenance therapy for the treatment of depressive illness: a response to the National Institute for Excellence report. Journal of ECT, March; 22(1): 13-17.
Geddes J, Carney S, Cowen P, et al. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet, 361 (9360): 799-808.
Greenberg, R., et al. (2005). Electroconvulsive Therapy: A Selected Review, American Journal of Geriatric Psychiatry, April 13(4).
Kahn, D; Carpenter, D; Docherty, J; Frances, A. Treatment of Bipolar Disorder (no date).
Lisanby, S. (2007). Electroconvulsive Therapy for Depression. New England Journal of Medicine, 357: 19: 1939-1945. Available at http://www.nejm.org. Accessed on April 28, 2009.
National Institute for Clinical Excellence (NICE) (2003, April). Guidance on the use of electroconvulsive therapy. Technical Appraisal 59. London, UK: NICE. Available at http://www.nice.org.uk/Docref.asp?d=68306. Accessed on April 28, 2009.
Onofrj, M, Thomas, A. (2005). Acute akinesia in Parkinson s disease. Neurology 2005; 64: 1162.
Sackeim, H, Haskett, R, Mulsant, B, et al. (2001). Continuation pharmacotherapy in the Prevention of Relapse following electroconvulsive therapy. The Journal of the American Medical Association, 285: 1299-1307. Available at: http://jama.ama-assn.org/cgi/content/full/285/10/1299. Accessed on May, 11, 2009.
Smith, D. (1995). Neuroleptic Malignant Syndrome. P&T News April, 1995, Volume 15, No. 10. Available at: http://www.healthcare.uiowa.edu/pharmacy/PTNews/1995/04.95.html. Accessed on June 1, 2009.
U.S. Department of Health and Human Services (2001, December), Office of the Inspector General. Medicare Reimbursement for electroconvulsive therapy. OEI-12-01-00450. Washington, DC; U.S. Department of health and Human Services. Available at http://oig.hhs.gov/oei/reports/oei-12-01-00450.pdf. Accessed on April 29, 2009.
US Department of Health and Human Services, €œClinical Practice Guidelines €, pp. 41, 95-96.
Illinois 09/16/2009
Michigan 09/09/2009
Minnesota 09/24/2009
Wisconsin 09/25/2009
J5 MAC 10/08/2009
Jurisdictional Open Meeting 08/19/2009
Start Date of Comment Period
Michigan 09/09/2009
Minnesota 09/24/2009
Wisconsin 09/25/2009
J5 MAC 10/08/2009
Jurisdictional Open Meeting 08/19/2009
10/08/2009
End Date of Comment Period
11/23/2009
Start Date of Notice Period
06/01/2010
Revision History Number
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0901 was changed
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
00104 descriptor was changed in Group 1
02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
06/01/2010
Related Documents
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LCD Attachments
Coding and Billing Guidelines 06/01/2010 (PDF - 35,111 bytes )
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