CMS Pub. 100-02, ch. 15, § 160

A. Clinical Psychologist (CP) Defined

To qualify as a clinical psychologist (CP), a practitioner must meet the following

requirements:

Hold a doctoral degree in psychology;

Be 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.

B. Qualified Clinical Psychologist Services Defined

Effective July 1, 1990, the diagnostic and therapeutic services of CPs and services and

supplies furnished incident to such services are covered as the services furnished by a

physician or as incident to physician’s services are covered. However, the CP must be

legally authorized to perform the services under applicable licensure laws of the State in

which they are furnished.

C. Types of Clinical Psychologist Services That May Be Covered

Diagnostic and therapeutic services that the CP is legally authorized to perform in

accordance with State law and/or regulation. A/B MACs (B) pay all qualified CPs based

on the physician fee schedule for the diagnostic and therapeutic services. (Psychological

tests by practitioners who do not meet the requirements for a CP may be covered under

the provisions for diagnostic tests as described in §80.2.

Services and supplies furnished incident to a CP’s services are covered if the

requirements that apply to services incident to a physician’s services, as described in §60

are met. These services must be:

• Mental health services that are commonly furnished in CPs’ offices;

• An integral, although incidental, part of professional services performed by the

CP;

• Performed under the direct personal supervision of the CP; i.e., the CP must be

physically present and immediately available;

• Furnished without charge or included in the CP’s bill; and

• Performed by an employee of the CP (or an employee of the legal entity that

employs the supervising CP) under the common law control test of the Act, as set

forth in 20 CFR 404.1007 and §RS 2101.020 of the Retirement and Survivors

Insurance part of the Social Security Program Operations Manual System.

• Diagnostic psychological testing services when furnished under the general

supervision of a CP.

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.

G. Assignment Requirement

Assignment is required.