ED Coding and Reimbursement Alert

Since your emergency department (ED) physician probably performs several psychiatric evaluations a day, you may need to freshen up on your psychiatric coding lingo if you can't tell when to bill a 99285 versus a 90801. 

Psychiatric visits in the ED are common, and their parameters can vary greatly. Since there is a large difference in services provided to an acutely suicidal or psychotic patient and a patient with a less severe psychiatric episode, coding can often become complicated. The key to coding various scenarios is in the documentation of services provided, which will increase with the severity of the patient's problem. Also, you need to know when to bill the psychiatric instead of the E/M codes.

Psychiatric Codes Need Meticulous Documentation
 
The psych series of outpatient codes (90801-90809) has a unique function, independent of the typical medical E/M services, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. "These codes are specifically for psychotherapy, a talk-therapy discipline involving evocation of insight, behavior modification, and a variety of other approaches to secure an improvement in the patient's psychiatric condition," he says.

Emergency physicians provide psychiatric patients with directive and supportive counseling in very limited ways, such as calming patients, reassuring them of their safety, and offering thoughts as to explain their experience, Blakeman says.

Although ED coders rarely use the psych codes 90801 (Psychiatric diagnostic interview examination) and 90802 (Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication), these codes do not have a "place of service" restriction. You can use them in the ED with careful documentation and under appropriate circumstances described above. These psych codes require the presence of a psychiatric diagnostic or an evaluative interview that includes history, mental status and disposition, communication with family or other sources, and ordering and interpretation of laboratory or other medical diagnostic studies.

Most carriers do not deem the interview as medically necessary for patients with a previously established organic brain disorder unless there has been an acute or marked change in status. Also, the physician should conduct the interview only once at the outset of an illness, such as when the patient presents in the ED for the first time. The physician can only perform it again if the patient undergoes an extended hiatus from treatment or requires admission to inpatient status.

Make sure to support medical necessity with ICD-9 codes from the Mental Disorders series (290.0-318.1), such as 295.02 (Schizophrenic disorders, simple type, chronic).
 
Use 99285 for Severe Psych Cases

Your best bet is to code most regular psychiatric ED visits using the appropriate E/M code (99281-99285). Kim Myers, CCS-P, CPC, president of Emergency Billing Services Inc. in Lake Milton, Ohio, recommends staying away from the psychiatric codes in most cases. She explains that the level of service done performing 90801 (or 90802 with the medical examination) is approximately equal to a level-five E/M visit. Reimbursement for the psychiatric codes, however, is usually less than for a level-five visit. Most ED physicians' services are more E/M-related, since they most often perform examinations to give medical clearance, Myers says. Only a part of their services involves psychiatric techniques.

For instance, the physician may see a regular psychiatric patient in the ED who requires a screening and medication refill and then can be released. The next day, the ED physician may see several suicidal or psychotic patients who require extensive visits with various tests. The first scenario may justify billing only a lower-level 9928x code, while the latter corresponds to a level-five visit. The complexity level of the tests, history, evaluation and subsequent documentation of these factors will help you decide which code is appropriate. Take a look at six case studies, provided by Blakeman, to see when you would report each E/M level:

Case Study 1: Coding 99281. An asymptomatic patient who is well known to the ED physician stops by for a Zoloft prescription refill because his physician is out of town. The physician does not perform any testing and does a brief vital-signs assessment. Due to the limited history and physical, this represents the lowest level of service

Case Study 2: Coding 99282. A patient who had an argument with his significant other and "needed someone to talk to" presents in the ED. No testing is needed. The physician performs a vital-signs assessment and a brief orientation exam and neurological status with a history of the complaint noted.

Case Study 3: Coding 99283. An asymptomatic patient not now intoxicated is sent to the ED by a social worker or psychiatrist for a psychiatric clearance before admission to an alcohol rehabilitation unit. The physician takes vitals and performs heart and neurological exams with minimal labs, such as a complete blood count and ethyl alcohol (ETOH) level. Although moderate medical decision-making is present, this case would only qualify for a level-three H&P.

Case Study 4: Coding 99284. A patient complaining of hearing voices, having a headache and wanting the voices to go away presents in the ED. The physician performs an exam including vitals, heart, lungs, abdomen, neurological, extremities and metabolic panel with an electrocardiogram.

Case Study 5: Coding 99285. A patient with severe depression and suicidal ideation, with or without a plan, presents in the ED. The physician orders a full physical examination and full workup with metabolic panel, CBC, drug screen, EKG and chest x-ray. The patient may or may not require admission, but the physician refers him for a psych follow-up.

Case Study 6: Critical Care (99291-99292). The physician spends 30 minutes attending to a drug-overdose patient who is attempting to hurt himself and is striking the ED staff. He is resistant to initial pharmacological restraint and requires careful monitoring and full H&P, labs, EKG and x-rays.