Code 90853

Are there any psych billers out there? Why would Medicare not want to pay this in a nursing home? I cannot find any guidelines
Thanks

Code 90853

There's a medlearn matters article on psychiatry, SE0816 published July 2008, Effective date 7/30/08, which references all the manuals. Perhaps that would help.

Is the provider who is doing the service qualified under Medicare rules? maybe you'll have to call them.

NHIC says only this:
Group Psychotherapy
Group psychotherapy is a form of treatment in which a carefully selected group of patients are
guided by a licensed psychotherapist for the purpose of helping to effect changes in maladaptive
patterns which interfere with social functioning and are associated with a diagnosable psychiatric
illness.
90853 Group psychotherapy (other than of a multiple-family group)
90857 Interactive group psychotherapy
CONTRACTOR NOTE: Group psychotherapy must document the actual number of participants
at each session.
CONTRACTOR NOTE: More than one group therapy code billed on the same date of service by
the same provider is not allowed although one individual and one group therapy billed on the
same date of service by the same provider can be paid if reasonable and necessary for the
condition of the patient and fully documented in the patient’s records.

90853

Many of the initial medical records from nursing homes did not include any specific psychiatric documentation. In all of these cases, Medicare will ask the nursing home for documentation on the psychiatric service(s) provided. Medical necessity of the service will be based solely on the information provided in the medical record.

90853

So, even though the physician has his/her documentation, Medicare will look at the nursing home records to see if it is documented there??

nursing home Pschytric services

Over one third of Medicare payments for psychiatric services in nursing homes are inappropriate, according to OIG after review of records. The review found that 27 percent of psychiatric services provided in nursing homes are medically unnecessary. More than half of unnecessary services are provided to individuals whose cognitive limitations make them unable to benefit from the psychiatric intervention, and about half have an inappropriate frequency and/or duration. Additionally, many medically unnecessary services do not appear to stabilize or improve patients’ conditions.
Medicare Psychiatric Services in Nursing Homes OEI-02-99-00140

90853

Who is providing the group psychotherapy? Are the diagnosis codes reported for the group members actually conditions which are treatable by psychotherapy? If the nursing home has a social worker gather a bunch of patients for "group" because they should have more interpersonal interactions and stimulation and talking about things is good, it would be hard to support medical necessity, especially if the patients were cognitively impaired or on the list of conditions that Medicare believes are not able to be improved by psychotherapy.
I wouldn't enroll a patient in a group without a psychiatric diagnostic eval, a improvable diagnosis, a treatment plan, and a provider who follows the documentation guidelines.