Medicare Local Medical Review Policies Tool Kit

Part III: The Tools • LMRP Language: From Bad to Better • Examples of Recent Developments in Coverage for Psychological Services • Sample Correspondence to Carriers • Empirical Evidence for Psychological Services • Resources

Toolkit Home Part I: LMRP Basics Part II: Opportunities for Involvement Part III: The Tools Appendices

Part III. Tools for Becoming Involved

LMRP Language: From Bad to Better

This section provides a wide variety of examples of problematic language that has appeared in drafts of LMRPs and that needs to be carefully addressed by psychologists. While these specific examples may or may not be relevant to your local policy language, they demonstrate the need for vigilance and fine-tuned attention to the potential for mistaken and misleading statements about psychological services.

Problem: Proposed policy language requires written informed consent for treatment by psychologist:

Comments: Written informed consent is not mandated for other specific classes of professional services. Consent for billing is in the form of a signature on file. Older adults are often instructed by family not to sign any papers for fear of financial abuse. When a distressed or agitated patient requires assessment or treatment by a psychiatrist, psychologist or other mental health professional, requiring written as opposed to the usual verbal consent for treatment will unnecessarily delay urgently needed care. Psychiatric/psychological interventions, with the exception of medication, are minimally physically intrusive, and can not be performed without the consent and cooperation of the patient. Requiring the patient to sign a legal document at time of acute emotional/behavioral disturbance presents an unjustified barrier to receiving appropriate, timely care.

Problem: Proposed policy language requires psychiatrist or physician oversight for psychological services:

Comments: Except where otherwise required under the Social Security Act, Medicare allows for the independent practice of clinical psychology. The attending physician must order nursing home psychiatric and psychological services. However, psychiatry and psychology are independent professions and psychologists do not require psychiatric oversight.

Problem: Proposed policy language includes too narrow definition of reasonable and necessary:

Bad language: There must be a reasonable expectation of improvement in the patient's disorder or condition, demonstrated by an improved level of functioning, from the intervention provided.

Better language: There must be a reasonable expectation of improvement in the patient's disorder or condition, demonstrated by an improved level of functioning, or maintenance of level of functioning when a decline would otherwise by expected.

Problem: Proposed policy language includes bias toward one class of provider:

Bad language: The type, frequency, and duration of services must be medically necessary for the patient's condition under accepted medical and psychiatric practice standards and relate directly to the written treatment plan.

Better language: The type frequency, and duration of services must be medically necessary for the patient's condition under accepted practice standards and relate directly to the written treatment plan.

Bad language: For all psychiatric "incident to" services rendered in the home, skilled nursing home, or partial hospitalization, the physician must be present in the same room as the individual performing the service and participate in the delivery of the service.

Better language: For all psychiatric/psychological "incident to" services rendered in the home, skilled nursing home, or partial hospitalization, the billing provider must be present on the same unit as the individual performing the service and participate in the delivery of the service.

Problem: Proposed policy language states or implies that nurses, physician's assistants, or other paraprofessionals may practice psychotherapy:

Comment: Specific qualifications may vary by state. Check with your state's Nursing Board or Board for Medicine to make sure that the proposed policy language does not go beyond what state licensure allows in the practice of psychotherapy.

Problem: Proposed policy language indicates over-reliance on medications in treating older adults or other groups of beneficiaries:

Bad language: Psychotherapy is an effective adjunctive form of treatment for new psychiatric conditions, while other psychiatric illnesses primarily require treatment with medications.

Comment: This statement is unfounded and reflects a severe bias toward medication in treating older adults.

Bad language: Patients with major depressive disorders and bipolar disorders may also require treatment with medications. These medications must be documented in the patient's record when psychotherapy is rendered. If the provider of services is not licensed to prescribe medications, they must obtain this information from the prescribing physician. If the patient is not being treated with medications, he must be referred to a psychiatrist for evaluation and treatment with medication before continuing psychotherapy services.

Comment: Medications are often helpful in treating depression. The data of the NIMH collaborative depression study indicate that medication and psychotherapy are about equally effective in the treatment of depression, and that the combined treatment is more effective than either modality alone. As a mater of good clinical practice, most patients should be considered for both medication and psychotherapy and decisions made on a case by case basis. A patient who refuses one effective form of treatment, such as medication, should not be denied access to the alternative effective treatment.

Problem: Proposed policy language includes misstatements or overgeneralizations about specific mental health problems:

Bad language: To benefit from psychotherapy, an individual must be cognitively intact and able to engage the therapist in meaningful verbal interaction.

Better language: To benefit from psychotherapy, an individual must be cognitively intact to the degree that he/she can engage in a meaningful verbal interaction with the therapist (except for family therapy without the patient present, and where interactive psychotherapy is necessary). Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent establishment of a relationship with the therapist which allows insight-oriented, behavior-modifying or supportive therapy to be effective. The type and degree of dementia must be taken into account in planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a patient with dementia, the patient's record should document that the patient's cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

Bad language: Psychotherapy services for individuals with cognitive impairment can be more effectively carried out with signs and symbols and/or physical aids to communicate.

Comment: This language represents a gross overgeneralization about people with cognitive impairments. A large number of people have subtle cognitive impairments of varying types that go socially and clinically unnoticed. For example, 10 percent of the population in normal public schools are classified as having learning disabilities. In addition, significant numbers are mildly retarded, language impaired, or otherwise developmentally disabled. Similarly, some cognitive changes are common even in the relatively intact elderly, while other individuals are severely and profoundly impaired. We need to be careful not to over generalize and discriminate against a large class of citizens, and in doing so, deny them needed mental health care.

Problem: Proposed policy language unduly restricts number of treatment sessions:

Bad language: Interactive psychotherapy is not a treatment that is required or rendered on an ongoing basis or indefinitely for every patient. Some conditions, such as adjustment disorder or reactive depression require a shorter duration of therapy, i.e., 4-8 sessions to alleviate the condition. Severe depression or schizophrenic conditions might require 15-20 sessions. The only exceptions are certain personality disorders that may require long term therapy, but even these disorders do not need to be treated biweekly or weekly indefinitely.

Comment: If these numbers are meant as treatment limits they are inappropriate. A much better statement provides that the duration of psychotherapy must be individualized for every patient. The coverage for ongoing psychotherapy is available only if there is demonstrable indication that the beneficiary is obtaining continuing benefits. The carrier will monitor the frequency and total number of sessions rendered to individual beneficiaries.

Problem: Proposed policy language is inconsistent with evidence:

Numerous provisions may fit into this category; psychologists reviewing LMRP's must be vigilant for policy provisions that may reflect assumptions by non-psychologists, or may simply be vestiges of obsolete statements about psychology. Examples that have been noted in prior policies include an arbitrarily limited list of diagnoses that are appropriate for group therapy and a statement that only "physicians and psychologists are formally trained in administration and interpretation of psychological tests."

The best response is to note the discrepancy, suggest a more accurate statement, and present the leading evidence that supports the correction.

Problem: Policy language presents an ethical dilemma for psychologists:

Bad language: Documentation for group therapy requires that group note common to all patients be included in each patient's file.

Comment: Documenting the names of other patients in a given patient's chart creates problems of confidentiality and is generally prohibited.

Problem: Policy language refers to outmoded test procedures or provides unreasonable time limitations for billing for psychological testing:

Example: Some policies included references to the MMPI and WAIS-R after the MMPI-2 and WAIS III were in wide practice. Additionally, policies have provided time limits such as 45 minutes for an older patient to complete the MMPI or other test procedures.

The best response is to update the tests, or suggest that types of tests be substituted for specifically named instruments. Realistic time limits should be demonstrated. Also, behavioral observations are an essential part of psychological testing, and one which has been stressed by the APA Working Group on Older Adults. Make sure reasonable provision of time for scoring and interpretation is included.

Problem: Policy language unduly restricts the use of psychological testing:

Bad language: When a psychiatric condition or the presence of dementia has already been diagnosed, there is no value to the tests, except when there is an observation by the attending physician that there is a significant change in the patient's mental condition and the diagnosis is uncertain.

Comment: Testing has value when it contributes instrumentally to the care of the patient. For example, we may know that a patient has some dementia, but not know to what extent the dementia makes it unsafe to live independently. For a patient for whom caregivers or family have to make such decisions, testing may be essential. The reference to the attending physician oversight is also inappropriate except in nursing home settings.

Bad: Psychological testing is not indicated when the beneficiary has an apparent adjustment disorder or dysphoria after moving to a nursing home.

Comment: This limitation on psychological testing is not in the best interests of patients. Often patients move into nursing homes because of a decline in physical health or ability to care for themselves. The mere fact that they are experiencing dysphoria at the move should not mean that they might not have coexisting problems that need to be investigated. Obviously, many patients who move into nursing homes will feel some degree of adjustment problems that will pass naturally without professional involvement. But they need to be looked at on a case by case basis.

Bad language: Psychological testing for established psychiatric diagnoses will be denied as not medically necessary.

Comment: Testing is not only used to make a diagnosis, but to answer specific questions about the individual's functioning and needs beyond just the diagnosis. If a patient has an established diagnosis of dementia and we need to determine whether he/she has the judgment and cognitive capacity to care for him/herself in specific, relevant situation, the diagnosis may remain dementia, but the testing was necessary.

Examples of Recent Developments in Coverage for Psychological Services

Several states have recently changed their policy language to more accurately reflect psychology's current understanding of the course of dementia as well as the current state of available treatment options. Psychologists were heavily involved in the process resulting in beneficial changes in New York, Connecticut and Minnesota.

Specific Changes in Policy Language

The New York LMRP was revised to include consideration of the multiple stages of dementia in determining appropriate treatment:

To benefit from psychotherapy, an individual must be cognitively intact to the degree that he/she can engage in a meaningful verbal interaction with the therapist (except for family therapy without the patient present, and where interactive psychotherapy is necessary). Psychotherapy services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent establishment of a relationship with the therapist which allows insight-oriented, behavior-modifying or supportive therapy to be effective. The type and degree of dementia must be taken into account in planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a patient with dementia, the patient's record should document that the patient's cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

The New York LMRP also benefited from input by psychologists in its coverage provisions for psychological and neuropsychological testing. It provides that:

Additional testing after a diagnosis of dementia may be considered reasonable and necessary if it can be expected to aid in evaluation of a patient's capacity to function in a given situation, to have a significant impact on management of the patient, or to help tailor therapeutic techniques.

On a more general level, the New York LMRP departs from a rigid medical model by providing the following language in place of reference to "malformed body members" (the traditional language used in older policies to support medical necessity):

There must be a reasonable expectation of improvement in the patient's disorder or condition, demonstrated by an improved level of functioning, or maintenance of level of functioning where decline would otherwise be expected in the case of a disabling mental illness or condition or chronic mental disorder.

LMRPs in Connecticut and Minnesota were recently revised to include consideration of comorbid conditions with dementia, which may also bear on medical necessity and result in access to care for more older adults:

Dementia and Alzheimer's disease in nursing homes is fairly common. Most of the time the attending physician, usually a general internist, family practitioner or geriatrician manages these patients and it is not medically necessary to follow these patients more frequently than once a month. Medicare provides coverage for all medically necessary evaluations.

Patients with dementia with complications such as paranoia, agitation, and depression may require psychiatric/psychotherapeutic care to adequately assess their emotional and behavioral symptoms, their mental status and their ongoing treatment needs.

The standard of care during the initial evaluation by psychiatry in such patients includes pertinent medical, pharmacologic, laboratory, psychiatric and environmental findings that may have influenced the new/additional symptoms and may influence further care.

After the initial evaluation and stabilization of the psychiatric complications(s), the follow-up should be infrequent and for the purpose of monitoring the clinical status. As the patient becomes stable on the treatment, the intervals between the evaluations should become less frequent.

Change of National Policy on Coverage Determinations

A recent CMS Program Memorandum indicates current awareness of the problem of automatic denial of claims when a diagnosis of dementia is present. Transmittal AB-01-135, dated September 25, 2001, entitled "Medical Review of Services for Patients with Dementia," states that carriers may not include provisions that result in automatic denial of claims based solely on a diagnosis of dementia. The memorandum notes that new developments in neuropsychiatric testing enable physicians and psychologists to diagnose some dementias at early stages so that throughout the ensuing disease process, many patients may benefit from pharmacologic, physical, occupational, speech-language, and other therapies.

Relevant to psychologists' complaints that claims appear to be automatically denied even where the language of the LMRP does not support the practice, the Program Memorandum further states that carriers "may not use ICD-9 codes for dementia alone as a basis for determining whether a Medicare covered benefit was reasonable and necessary because these codes do not define the extent of a beneficiary's cognitive impairment."

See CONA's initial 2001 report Overview of Medicare Coverage for Psychological Services for Patients with Diagnoses of Dementia or Alzheimer's Disease http://www.apa.org/pi/aging/overviewmedcare.html

Sample Correspondence

General tips for Securing Input

Although individual psychologists can raise the awareness of the local carrier of areas of import to psychology, most likely, initial efforts to secure psychologists' input into the draft LMRP development process will reflect preliminary work and planning by a committee of psychologists. This may be the state-level psychological organization [link to list of SPAs] or other group of psychologists. The Carrier Advisory Committee process has built-in respect for efforts and presentations by professional societies, so that it may be a good idea for the initial and ongoing communications to demonstrate an organized group.

Correspondence and other interactions with the Carrier Medical Director and the Carrier Advisory Committee should therefore strive to: a) reflect the efforts of a specialized group of psychologists with collective knowledge and experience in the field; b) should emphasize the ability of psychologists to be of assistance to those responsible for policy language; and c) should emphasize a scientific, evidence-based approach to specific items currently at issue.

Letter to request a meeting with the Carrier Medical Director

Dear Dr. [name of CMD]:

As the [name of group or committee], we have been charged with the task of representing the interests of psychologists and their patients in the area of Medicare coverage for necessary psychological services. We have been following with interest the recently proposed LMRP draft, particularly sections ____, providing policy language regarding ______________________.

We believe that we may be of particular assistance to the Carrier Advisory Committee in making final decisions about the proposed language, based on our specialized knowledge of the clinical research supporting current practice in this area, as well as our collective experience with patients requiring these very services.

Accordingly, we are writing to request a brief meeting with you, in the hopes of discussing the best possible way for us to be of assistance in the development of this LMRP. We have information and evidence which bears directly on the decisions to be made, and would like to discuss further the best format for providing it in the most helpful manner.

Written comments to proposed policy language:

Dear Dr. [name of CMD]:

We are writing on behalf of [ ], an organization of psychologists who [your area of expertise]. We would like to express our concern regarding Note 11 under Section III: Psychiatric Therapeutic Procedures of your local medical review policy (LMRP) for psychiatry and psychology services. This provision states, in pertinent part:

In a nursing home setting, if a patient is treated for a mental health problem, psychotherapy is medically inappropriate unless the treating physician recognizes that there is an inadequate response to medical treatment and he/she specifically authorizes psychotherapy. In the absence of such authorization, psychotherapy would be considered professionally unethical and inappropriate, and would constitute a duplicative service.

This limitation is inconsistent with medical science and clinical practice in several respects. Declaring psychotherapy to be "medically inappropriate unless the treating physician recognizes that there is an inadequate response to medical treatment" is inconsistent with empirical research. It has been demonstrated that, in both younger and older adults, psychotherapy in conjunction with pharmacotherapy is significantly more effective in treating mental health problems than is pharmacotherapy alone (Arean & Cook, 2002; de Jonghe, Kool, van Aalst, Dekker, & Peen, 2001). Moreover, there are instances when psychological interventions are more appropriate than medication, especially for older adults, and even more so nursing home residents, who are at increased risk for adverse pharmacological side effects and drug interactions. Note 11 further seems to encourage the prescribing of medications in nursing homes, which is in contradiction to federal monitoring efforts that are geared toward decreasing the use of medication by long-term care residents when other treatments are available. In addition, benefits provided by psychotherapy should not be considered "duplicative," as Note 11 indicates. Rather, psychotherapy frequently offers benefits that are distinct from, or complementary to, the benefits of medication therapy. It is also important to recognize that many psychotropic medications (e.g., antidepressants) typically require several weeks to take effect, whereas psychotherapy can provide more immediate relief. This is an especially significant consideration with individuals in severe distress. Additionally, Note 11, when read in its entirety, suggests that mental illness in nursing home residents consists exclusively of dementia-related symptoms. Although dementia is highly prevalent in nursing homes, other mental disorders are highly prevalent in this setting (Strahan & Burns, 1991), including depression, anxiety, and personality disorders in the absence of dementia.

We assume that one intention of Note 11 is to coordinate psychological services with medical care. This important collaboration is accomplished by the CMS Medicare requirement that psychologists inform a patient's primary physician when the patient is receiving psychological services. However, requiring that physicians specifically authorize psychotherapy likely causes many older adults with significant mental health problems to go untreated. Research has shown that physicians commonly fail to detect mental disorders in elderly individuals, which are often mistakenly attributed to organic illness or normal age-related changes (Mackenzie, Gekoski, & Knox, 1999). Less than 10% of nursing home residents in need of mental health care receive treatment, including medication (AARP Public Policy Institute, 1994). The AARP Public Policy Institute concluded in its report of mental health services in nursing homes, "Despite the high prevalence of mental disorders among nursing home residents and the beneficial impact that mental health treatment could have for many of these residents, mental health services are scarce in this setting" (AARP Public Policy Institute, 1994, p. 45). Furthermore, physicians are often not able to closely monitor psychological and behavioral changes in patients residing in long-term care facilities. Psychologists providing psychotherapy, however, are in a better position to evaluate changes in the patient and provide information to the physician about responses to treatment.

As it is written, Note 11 is discrepant with Chapter 13 of the Medicare Program Integrity Manual (PIM), which requires that "Contractors develop LMRPs by considering medical literature, the advice of local medical societies and medical consultants and public comments" (PIM, Ch. 13, Sec. 1.3). The PIM further requires that LMRPs be based on "the strongest evidence available" (PIM, Ch. 13, Sec. 7.1). In light of its inconsistency with medical science, current medical evidence, and clinical practice, we request that you remove the section from Note 11 quoted above from your LMRPs.

Thank you for your attention to our concerns. Please feel free to contact us if you have any questions or would like to discuss this matter further.

Empirical Evidence for Psychological Services

Allen-Burge, R., Stevens, A.B., & Burgio, L.D. (1996). Effective behavioral interventions for decreasing dementia-related challenging behavior in nursing homes. International Journal of Geriatric Psychiatry, 14, 213-228.

Banazak, D.A. (1997). Anxiety disorders in elderly patients. Journal of the American Board of Family Practice, 10, 180-289.

Banerjee, S., & Dickinson, E. (1997). Evidence based health care in old age psychiatry. International Journal of Psychiatry in Medicine, 27, 283-292.

Bourgeois, M.S., Schultz, R., & Burgio, L.D. (1996). Interventions for caregivers and patients with Alzheimer 's disease: A review and analysis of content, process, and outcomes. International Journal of Aging & Human Development, 43, 35-92.

Brody, D., Dietrich, A.J., & deGruy, F. (2000). The depression in primary care toolkit. International Journal of Psychiatry in Medicine, 30, 99-110.

Burgio, K.L. (1998). Behavioral vs drug treatment for urge urinary incontinence in older women: A randomized controlled trial. Journal of the American Medical Association, 280.

Callahan, C.M., Hendrie, H.C., Dittus, R.S., Brater, D.C., Hui, S.L., & Tierney, W.M. (1994). Improving treatment of late life depression in primary care: A randomized clinical trial. Journal of the American Geriatrics Society, 42, 839-846.

Cuijpers, P. (1998). Psychological outreach programmes for the depressed elderly: A meta-analysis of effects and dropouts. International Journal of Geriatric Psychiatry, 13, 41-48.

Engels, G.I., & Verney, M. (1997). Efficacy of nonmedical treatments of depression in elders: A quantitative analysis. Journal of Clinical Geropsychology, 3, 17-35.

Gallagher-Thompson, D., Hanley-Peterson, P., & Thompson, L.W. (1990). Maintenance of gains versus relapse following brief psychotherapy for depression. Journal of Consulting and Clinical Psychology, 58, 371-374.

Gallagher-Thompson, D., & Thompson, L.W. (1994). Psychotherapy with older adults in theory and practice. In B. Bongar & L. Beutler (Eds.), Foundations of psychotherapy: Theory, research, and practice. New York: Oxford University Press.

Gatz, M., Fiske, A., Fox, L.S., Kaskie, B., Kasl-Godley, J., McCallum, T.J., & Wetherell, J.L. (1998). Empirically validated psychological treatments for older adults. Journal of Mental Health and Aging, 4, 9-46.

Gerson, S., Belin, T.R., Kaufman, A., Mintz, J., & Jarvik, L. (1999). Pharmacological and psychological treatments for depressed older patients: A meta-analysis and overview of recent findings. Harvard Review of Psychiatry, 7, 1-28.

Groth-Marnat, G. (1996). Professional psychologists in general health care settings: A review of the financial efficacy of direct treatment interventions. Professional Psychology Research and Practice, 27.

Hartmann-Stein, P.E. (1998). Hope amidst the behavioral healthcare crisis. In P.E. Hartmann-Stein (Ed.), Innovative behavioral healthcare for older adults (pp. 201-214). San Francisco: Josey-Bass Publishers.

Kasl-Godley, J., & Gatz, M. (2000). Psychosocial interventions for individuals with dementia: An integration of theory, therapy, and a clinical understanding of dementia. Clinical Psychology Review, 20, 755-782.

Laidlaw, K. (2001). An empirical review of cognitive therapy for late life depression: Does research evidence suggest adaptations are necessary for cognitive therapy with older adults. Clinical Psychology and Psychotherapy, 8, 1-14.

Mossey, J.M., Knott, K.A., Higgins, M., Talerico, K. (1996). Effectiveness of a psychosocial intervention, interpersonal counseling, for subdysthymic depression in medically ill elderly. Journal of Gerontology, 51A, 4, M172-M178.

Mittelman, M.S., Ferris, S.H., Shulman, E., Steinberg, G., & Levin, B. (1996). A family intervention to delay nursing home placement of patients with Alzheimer disease: A randomized controlled study. Journal of the American Medical Association, 276, 1725-1731.

Niederhe, G. (1994). Psychosocial therapies with depressed older adults. In L.S. Schneider, C.F. Reynolds, B.D. Lebowitz, & A.J. Friedhoff (Eds.), Diagnosis and treatment of depression in late life: Results of the NIH Consensus Development Conference. Washington, DC: American Psychiatric Press.

Opie, J., Rosewarne, R., & O'Conner, D.W. (1999). The efficacy of psychosocial approaches to behavior disorders in dementia: A systematic literature review. Australian & New Zealand Journal of Psychiatry, 33, 789-799.

Pinquart, M., & Soerensen, S. (2001). How effective are psychotherapeutic and other psychosocial interventions with older adults? A meta-analysis. Journal of Mental Health and Aging, 7, 207-243.

Qualls, S.H. (2000). Therapy with aging families: Rationale, opportunities and challenges. Aging & Mental Health, 4, 191-199.

Reynolds, C.F., Frank, E., Perel, J.M., Imber, S.D., Cornes, C., Miller, M.D., Mazumdar, S., Houck, P.R., Dew, M.A., Stack, J.A., Pollock, B.G., & Kupfer, D. J. (1999). Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 281, 1, 39-45.

Robinson, L.A., Berman, J.S., & Neimeyer, R.A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49.

Schneider, L.S. (1995). Efficacy of clinical treatment for mental disorders among older persons. In M. Gatz (Ed.), Mental Health and Aging (pp. 19-69). Washington, DC: American Psychological Association.

Scogin, F., & McElreath, L. (1994). Efficacy of psychosocial treatments for geriatric depression: A quantitative review. Journal of Consulting & Clinical Psychology, 62, 69-74.

Seligman, M.E. (1995). The Effectiveness of Psychotherapy: The Consumer Reports Study. American Psychologist, 50, 965-974.

Small, G.W., Rabins, P.V., Barry, P.P., et al. (1997). Diagnosis and treatment of Alzheimer 's disease and related disorders: Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. Journal of the American Medical Association, 278, 1363-1371.

Smyer, M.A., Zarit, S.H., & Qualls, S.H. (1990). Handbook of the psychology of aging (3rd Ed). In J.E. Birren & K.W. Schaie. (Eds.), The Handbooks of Aging (pp. 375-403). San Diego: Academic Press, Inc.

Stanley, M.A., Beck, J.G., & Glassco, J.D. (1996). Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches. Behavior Therapy, 27, 565-581.

Teri, L., Curtis, J., Gallagher-Thompson, L.W. (1994). Cognitive/behavior therapy with depressed older adults. In L.S. Schneider, C.F. Reynolds, B.D. Lebowitz, & A.J. Friedhoff (Eds.), Diagnosis and treatment of depression in late life: Results of the NIH Consensus Development Conference. Washington DC: American Psychiatric Press.

Teri, L., Logsdon, R.G., Uomoto, J., & McCurry, S.M. (1997). Behavioral treatment of depression in dementia patients: A controlled clinical trial. Journal of Gerontology: Psychological Sciences, 52, 159-166.

Thompson, L.W., Coon, D.W., Gallagher-Thompson, D., Sommer, B.R., & Koin, D. (2001). Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression. American Journal of Geriatric Psychiatry, 9, 225-240.

Veterans' Health Administration (1997). Dementia Identification and Assessment Guidelines for Primary Care Practitioners. Washington DC: Department of Veterans Affairs.

Wetherell, J.L. (2002). Behavior therapy for anxious older adults. Behavior Therapist, 25(1), 16-17.

Zeiss, A.M. (1997). Treatment of late life depression. A response to the NIH Consensus Conference. Behavior Therapy, 28, 3-21.

Zeiss, A.M. (1996). Behavioral and cognitive-behavioral treatments: An overview of social learning. In S.H. Zarit & B.G. Knight (Eds.), A guide to psychotherapy and aging: Effective clinical interventions in a life-stage context (pp. 35-60). Washington DC: American Psychological Association.

Resources

The main source of information and linkage to Medicare carriers and local medical review policies www.lmrp.net

The Medicare Coverage Database includes National Coverage Determinations, National Coverage Analyses and LMRPs. http://cms.hhs.gov/coverage.

Medicare Program Integrity Manual, Chapter 13: http://www.hcfa.gov/pubforms/83_PIM/PIM83c13.htm

View monthly updates by Medicare carrier on the web: http://www.lmrp.net/ViewUpdatesStep1.asp

HHS OIG Report on Part B Policies for Mental Health Services http://oig.hhs.gov/oei/reports/oei-03-99-00132.pdf

ABA/Alzheimer's Medicare Advocacy Project Contact Leslie Fried

Alzheimer's Association www.alz.org

Medicare Learning Network http://www.cms.hhs.gov/medlearn

Medicare Rights Center www.medicarerights.org

CMS Regional Office Jurisdictions and Contact Information, http://www.cms.hhs.gov/about/regions/professionals.asp

Region I: Boston
Bill MacKenzie (William)
617.656.3857

Region II: New York
Kelli Singleton
212.264.8528

Region III: Philadelphia
Barbara Cerbone
215.861.4320

Region IV: Atlanta
Neil Logue
404.562.7382

Region V: Chicago
Greg Chesmore
312.353.1487

Region IV: Dallas
Pamela Kanawyer
214.767.6419

Region VII: Kansas City
Uvonda Meinholdt
816.426.5783 ext. 3444

Region VIII: Denver
Diane Livesay
303.844.7057

Region IX: San Francisco
Julia Cohen
415.744.3781

Region X: Seattle
Malvin White
206.615.2425

State Psychological Associations are listed at http://www.apa.org/practice/refer.html

APA Practice Directorate can answer general questions about Medicare and reimbursement issues. Call 202-336-5889 or go to www.apa.org/practice

For additional information related to psychological practice, call 202-336-5800 or go to www.apa.org/practice

The Medicare Handbook answers general questions about Medicare, such as how to become a Medicare provider. http://www.apa.org/practice/medtoc.html

APA Division 12 Section II (Clinical Geropsychology) was established to further the professional goals and interests of psychologists practicing with older adults, teaching the clinical psychology of aging, or conducting related clinical research. The Section has a Public Policy Committee that is active in Medicare Issues. Contact: Margaret Norris, Public Policy Chair

Psychologists In Long Term Care is a national network for psychologists working in long-term care settings. Part of its mission is to improve the access and quality of mental health services in long-term care settings. Contact: Margaret Norris, Coordinator or Nick Stilwell, Director of Membership

The APA Office on Aging maintains an Aging Issues Web Page that provides information on a wide range of aging issues for professionals, older adults and their families. http://www.apa.org/pi/aging

What Is CONA?

CONA is the American Psychological Association's Committee of Aging. It receives staff support from APA's Office on Aging, which in turn is housed under the APA Public Interest Directorate http://www.apa.org/pi/aging/homepage.html

The goal of CONA is to advance psychology as a science and profession and as a means of promoting human welfare by ensuring that older adults, especially the growing numbers of older women and minorities, receive the attention of the Association. CONA works toward the optimal development of older adults, expanded scientific understanding of adult development and aging, and the delivery of appropriate psychological services to older persons.

The APA Committee on Aging (CONA) and Office on Aging have embarked on the Local Medical Review Policy Project to work toward increasing the availability and coverage of psychological services for older adults under Medicare. For more information on CONA's Medicare LMRP Project http://www.apa.org/pi/aging/lmrp/

2003 CONA Members

Forrest Scogin, PhD (Chair)
(1/01 – 12/03)
Department of Psychology
University of Alabama
Tuscaloosa, Alabama

John Cavanaugh, PhD
(1/03-12/05)
Office of the President
University of West Florida
Pensacola, FL

Gregory A. Hinrichsen, PhD
(1/03-12/05)
Geriatric Psychiatry Division
Hillside Hospital, North Shore
Glen Oaks, NY

Leonard W. Poon, PhD
(1/02-12/04)
Gerontology Center
University of Georgia
Athens, Georgia

Beth Hudnall Stamm, PhD
(1/02-12/04)
Institute of Rural Health
Idaho State University
Pocatello, Idaho

Antonette Zeiss, PhD
(1/01 – 12/03)
VA Palo Alto Health Care System
Palo Alto, California

Submissions

The LMRP Project welcomes submissions from practitioners in all 50 states. If you have experience with your CMD or CAC or past correspondence that would be useful to other psychologists becoming involved in the LMRP process, please submit your comments, suggestions, and copies of correspondence to:

Deborah A. DiGilio, MPH
Staff Liaison to CONA and APA Aging Issues Officer
APA Office on Aging
750 First Street, NE
Washington, DC 20002-4242
(202) 336-6135
(202) 336-6040 FAX
Email